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Husak N, Leonard JB, Seung H, Klein-Schwartz W. Single-substance trazodone exposures reported to US poison centers from 2000 to 2019. Clin Toxicol (Phila) 2022; 60:1032-1038. [PMID: 35475757 DOI: 10.1080/15563650.2022.2068423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Individual case reports describe trazodone overdose resulting in QTc prolongation and cardiac arrhythmias. The clinical effects and outcomes associated with trazodone exposures on a large-scale basis are less well known. OBJECTIVE The primary objective was to characterize the severity of single substance trazodone exposures and identify any relationships that may exist between dose of trazodone and severity of exposure. The secondary objective was to describe these exposures from a demographic and clinical symptom standpoint. METHODS A retrospective review of single-substance trazodone exposures reported to the National Poison Data System (NPDS) from 1 January 2000 to 31 December 2019 was performed. The primary objective was to characterize the severity of trazodone exposures and relationships between ingested dose and level of care required or medical outcome. RESULTS A total of 118,773 cases were included in the analysis of demographics and level of care required. A majority (59.5%) of cases did not require medical admission. Of the 81,698 cases with known medical outcomes, the most common clinical effects included mild-moderate CNS depression (49.7%), QTc prolongation (12.2% of cases in 2019), vomiting (9.0%), hypotension (7.0%), and tachycardia (7.0%). The median ingested dose associated with treatment, and release from the emergency department was 600 mg compared to 1500 mg in those admitted to the intensive care unit (ICU). Regarding medical outcome, median ingested dose ranged from 600 mg in those experiencing no effect to 1500 mg in those experiencing major effects. Cardiac-related clinical effects and the need for cardiac-specific interventions were overall infrequent. A dose-response relationship was identified for level of care and medical outcome. CONCLUSIONS Many trazodone exposures can be characterized as low severity due to the infrequent need for healthcare facility admission and large proportion of cases that experienced no effects or only minor effects.
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Affiliation(s)
- Nicholas Husak
- Department of Pharmacy Practice and Science, Maryland Poison Center, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - James Brewer Leonard
- Department of Pharmacy Practice and Science, Maryland Poison Center, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Hyunuk Seung
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Wendy Klein-Schwartz
- Department of Pharmacy Practice and Science, Maryland Poison Center, University of Maryland School of Pharmacy, Baltimore, MD, USA
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Laudone TW, Leonard JB, Hines EQ, Seung H, Klein-Schwartz W. Changes in unintentional cannabis exposures in children 6 months to 5 years reported to United States poison centers during the first nine months of the coronavirus-19 pandemic. Clin Toxicol (Phila) 2022; 60:1029-1031. [PMID: 35471155 DOI: 10.1080/15563650.2022.2064867] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Almost half of exposures reported to United States (US) poison centers are exploratory ingestions in children under the age of 5 years. Pediatric cannabis exposures reported to US poison centers have risen over the last twenty years, with greater increases in the last 5 years. In 2020, the Coronavirus disease 2019 (COVID-19) pandemic resulted in widespread stay-at-home orders and subsequent changes in work, education, and daycare. This study describes the changes in pediatric cannabis exposures during the first nine months of the COVID-19 pandemic relative to the three years before the pandemic. METHODS Cases were identified from the National Poison Data System. Inclusion criteria was unintentional cannabis exposure in children aged 6 months to 5 years between January 1, 2017 and December 31, 2020. Analysis was performed with segmented regression of interrupted time series analysis comparing January 2017-March 2020 (pre-COVID-19) to April 2020-December 2020 (COVID-19 period). Autocorrelation was assessed using Dubin-Watson test. RESULTS There were 7,679 unintentional pediatric exposures from January 1, 2017 through December 31, 2020. There was a significant increase of 3.1% per month during the pre-COVID-19 period (p < .0001). A statistically significant immediate increase in number of exposures per month occurred in April 2020 (58.4%; p < .0001). The slope in the COVID-19 period was -0.01% (p = .99). No autocorrelation was detected. DISCUSSION AND CONCLUSIONS Unintentional cannabis exposures in children aged 6 months to 5 years reported to United States poison centers increased significantly after the initial COVID-19 stay-at-home orders. This trend may be associated with COVID-19 quarantines, increased time children are spending at home, increased availability of cannabis products in homes, or other reasons. Future efforts should evaluate specific factors that resulted in the observed increases in pediatric exposures.
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Affiliation(s)
- Thomas W Laudone
- Deparment of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA.,Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD, USA
| | - James B Leonard
- Maryland Poison Center, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Elizabeth Quaal Hines
- Maryland Poison Center, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA.,Department of Pediatric Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Hyunuk Seung
- Deparment of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Wendy Klein-Schwartz
- Maryland Poison Center, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA
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Leonard JB, Laudone T, Hines EQ, Klein-Schwartz W. Critical care interventions in children aged 6 months to 12 years admitted to the pediatric intensive care unit after unintentional cannabis exposures. Clin Toxicol (Phila) 2022; 60:960-965. [PMID: 35384771 DOI: 10.1080/15563650.2022.2059497] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Cannabis exposures in children have risen sharply in recent years, resulting in increased hospital visits and admission to pediatric intensive care units (PICUs). The intent of this study was to describe the proportion of pediatric patients admitted to the PICU after unintentional cannabis ingestion that received critical care interventions (CCIs) along with describing trends over time in hospitalization, admission to the PICU, and clinical effects and treatments outside of the PICU. METHODS This was a retrospective database study utilizing the National Poison Data System (NPDS) from 1/1/2000 to 12/31/2020. Children 6 months to 12 years of age with single substance cannabis exposures were included. RESULTS A total of 12,882 cases were included. There was an increase in the proportion of cases seen in a hospital over time from 43.8% in 2000 to 54.6% in 2020 (range 29.1-62.6%). In patients seen in a HCF, the proportion admitted to the PICU was 9.5% in 2000 and 14% in 2020 (range: 5.6-29.0%). The 875 (6.8%) children admitted to the PICU were analyzed for the primary outcome. CCIs were performed in 69/875 (7.9%) cases that were admitted to the PICU. The most common CCIs in the PICU were intubation and sedation, 4.9 and 3.7%, respectively. CONCLUSIONS Unintentional pediatric cannabis exposures are associated with clinically significant effects, including respiratory depression, hypotension, and bradycardia, but fewer than 5% of exposures were treated with CCIs, like intubation or vasopressors, in patients admitted to the PICU. Further work should assess specific reasons for admission to the PICU.
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Affiliation(s)
- James B Leonard
- Department of Pharmacy Practice and Science, Maryland Poison Center, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Thomas Laudone
- Deparment of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA.,Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD, USA
| | - Elizabeth Quaal Hines
- Department of Pharmacy Practice and Science, Maryland Poison Center, University of Maryland School of Pharmacy, Baltimore, MD, USA.,Department of Pediatric Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Wendy Klein-Schwartz
- Department of Pharmacy Practice and Science, Maryland Poison Center, University of Maryland School of Pharmacy, Baltimore, MD, USA
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Minhaj FS, Leonard JB, Seung H, Anderson BD, Klein-Schwartz W, King JD. In vitro analysis of n-acetylcysteine (NAC) interference with the international normalized ratio (INR). Clin Toxicol (Phila) 2021; 60:489-492. [PMID: 34549665 DOI: 10.1080/15563650.2021.1979232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Previous literature suggests a laboratory interference of n-acetylcysteine (NAC) with prothrombin time (PT) and the international normalized ratio (INR). Early publications focused on this interaction in the setting of an acetaminophen overdose and evaluated the INR of patients receiving intravenous NAC. However, there is limited literature describing the concentration-effect relationship of NAC to INR measurement in the absence of acetaminophen-induced hepatotoxicity at therapeutic NAC concentrations. The purpose of the study is to quantify the degree of interference of NAC on INR values at therapeutic concentrations correlating to each infusion of the regimen (ex. bag 1: 550 mcg/mL, bag 2: 200 mcg/mL, bag 3: 35 mcg/mL, double bag 3: 70 mcg/mL) and at supratherapeutic concentrations in vitro. METHODS Blood samples were obtained from study volunteers. Each blood sample was transferred into vials containing 0.3 mL buffered sodium citrate 3.2% and spiked with various concentrations of NAC for final concentrations of 0, 35, 70, 200, 550, 1000, 2000, and 4000 mcg/mL. The samples were centrifuged and tested to determine PT and INR on two separate machines: Siemens CS-2500 and Stago SN1114559. We would require a sample size of 6 to achieve a power of 80% and a level of significance of 1.7% (two-sided). Differences between INRs at varying concentrations were determined by Friedman's test. For multiple comparisons, post hoc analysis was performed using Wilcoxon signed-rank test with Bonferroni adjustment. Analyses were performed with SAS version 9.4 (SAS Institute, Cary, NC). RESULTS Participants included 11 healthy subjects: 8 males, 3 females, median age 30 years (range 25 - 58). Median and interquartile ranges (IQR) INR for the baseline samples were 1.09 (IQR 1.05, 1.16) for Siemens and 1.03 (IQR 0.99, 1.11) for Stago analyzers. There was a significant difference in INR between the therapeutic concentrations (baseline, 35, 70,200, or 550 µg/mL) (Siemens p = .0008, Stago p < .0001). The 550 µg/mL concentration with the Siemens analyzer was the only one compared separately and found to be significantly greater than the baseline (1.07 vs 1.22, p = .02). For the Stago analyzer the 200 µg/mL and 500 µg/mL were compared and found to be significantly different from baseline (1.00 vs 1.07 and 1.19, adjusted p = .02 and p = .03, respectively). The largest INR increase seen was in one subject from a baseline of 1.07-1.32 with the 550 µg/mL concentration. Increases in concentrations to supratherapeutic levels resulted in a statistically significant non-linear increase in INR for all concentrations (Siemens p < .0001, Stago p < .0001). All of these concentrations were found to be significantly different from baseline (all adjusted p < .05). CONCLUSION Although it was found that at therapeutic concentrations the in vitro presence of NAC affects INR measurements on two different machines, the change is of little clinical relevance. Supratherapeutic concentrations of NAC affect INR significantly, but the clinical utility of those results is limited by the rarity of those concentrations being measured.
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Affiliation(s)
- Faisal Syed Minhaj
- Maryland Poison Center, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - James B Leonard
- Maryland Poison Center, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Hyunuk Seung
- University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Bruce D Anderson
- Maryland Poison Center, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Wendy Klein-Schwartz
- Maryland Poison Center, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Joshua D King
- Maryland Poison Center, University of Maryland School of Pharmacy, Baltimore, MD, USA.,University of Maryland School of Medicine, Baltimore, MD, USA
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Leonard JB, Minhaj FS, Paterson E, Klein-Schwartz W. Exposures in pregnant patients reported to United States Poison Centers. Clin Toxicol (Phila) 2021; 60:356-361. [PMID: 34406096 DOI: 10.1080/15563650.2021.1968420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Limited data describe poisoning exposures in pregnant women. Previous studies are limited to inpatient populations, those seen only by toxicologists, or single poison centers. This study aimed to describe poison exposures reported to U.S. poison control centers in pregnant patients compared to non-pregnant controls. METHODS This was a retrospective observational study of exposures reported to the American Association of Poison Control Centers National Poison Data System from 2000 through 2019. Pregnant patients were included from 15-44 years along with a random sampling of 5:1 age and year matched control group of non-pregnant exposures. Demographics, primary substance, and known medical outcomes were described. Chi square analysis was performed for comparisons. RESULTS From 2000 to 2019, a total of 131,619 pregnant cases and 658,095 non-pregnant controls were identified. The median age was 27 years (IQR: 22, 31) for the matched groups. For known trimester of pregnancy: 29.8, 37.0, and 28.2% were in the first, second, and third trimester, respectively. Most common exposures were analgesics and cleaning products. Intentional exposures were more common in non-pregnant compared to pregnant cases (41.2 vs 21.9%; OR 2.71, 95% CI 2.67-2.75), mostly self-harm attempts (31.5 vs. 15.8%). Notably, there was a large discrepancy in the proportion of environmental exposures, with fewer in non-pregnant controls compared with pregnant cases (3.8 vs. 12.1%; OR 0.29, 95% CI 0.28-0.29). More non-pregnant cases had multiple substance exposures compared with pregnant cases (22.2 vs. 10.9%; OR 2.34, 95% CI 2.29-2.38). There were more moderate effect outcomes in non-pregnant compared with pregnant cases (13.2 vs. 6.3%; OR 2.25, 95% CI 2.20-2.30). CONCLUSIONS Outcomes of poisoning exposures in pregnant patients reported to U.S. poison centers are less serious compared to non-pregnant controls, likely due to the lower rates of intentional abuse and self-harm exposures and greater number of minimally toxic environmental exposures.
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Affiliation(s)
- James B Leonard
- Department of Pharmacy Practice and Science, Maryland Poison Center, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Faisal S Minhaj
- Department of Pharmacy Practice and Science, Maryland Poison Center, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Emily Paterson
- Department of Pharmacy Practice and Science, Maryland Poison Center, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Wendy Klein-Schwartz
- Department of Pharmacy Practice and Science, Maryland Poison Center, University of Maryland School of Pharmacy, Baltimore, MD, USA
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Minhaj FS, Leonard JB, Klein-Schwartz W. Clinical effects and outcomes of perampanel overdoses reported to U.S. poison centers. Clin Toxicol (Phila) 2021; 60:239-242. [PMID: 34275405 DOI: 10.1080/15563650.2021.1945083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Perampanel is indicated for partial onset seizures in children and adults. The mechanism is unique among antiepileptic agents as it inhibits glutamate activity on AMPA receptors. Currently, there are few published case reports describing overdose. METHODS This is a retrospective observational study of all single substance perampanel ingestions from January 2014 to December 2019 reported to the national poison data system (NPDS). The primary outcome is to describe the clinical effects of perampanel exposures. Secondary outcomes include evaluation of management and investigation of a dose-effect relationship for the purpose of triaging acute unintentional exposures. RESULTS A total of 138 exposures were reported to NPDS since the release of the agent. Median age was 20 years (IQR 10-38) with 68 (49.3%) males. The reason for exposure was most commonly therapeutic error (80, 58.0%), followed by exploratory ingestion (24, 17.4%), and suicidal ingestion (14, 10.1%). A total of six (4.3%) patients developed major effects, 20 (14.5%) moderate, 32 (23.2%) minor effects and 22 (15.9%) no effect. An additional 54 (39.1%) cases were not followed. Almost half of cases were managed at home. Of those that were in a healthcare facility (HCF) (n = 72), most were treated/evaluated and released (31, 43.1%), followed by admission to a non-critical care unit (20, 27.8%), and critical care unit (13, 18.1%). Most frequently reported symptoms were drowsiness (27, 19.6%), agitation (20, 14.5%), ataxia (13, 9.4%), and confusion (12, 8.7%). The most common therapies provided in a HCF were intravenous fluids (22,30.6%), followed by benzodiazepines (14, 19.4%), then other types of sedation (9, 12.5%). There were too few cases to determine a dose cut off for triaging. CONCLUSIONS While drowsiness, agitation, ataxia, and confusion were the most often reported symptoms, close to 19% developed moderate/major effects and almost 4% of patients received potentially life-saving interventions.
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Affiliation(s)
- Faisal Syed Minhaj
- Maryland Poison Center, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - James B Leonard
- Maryland Poison Center, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Wendy Klein-Schwartz
- Maryland Poison Center, University of Maryland School of Pharmacy, Baltimore, MD, USA
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Leonard JB, Seung H, Klein-Schwartz W. Impact of a drug safety communication on the severity of benzonatate exposures reported to poison centers. Pharmacoepidemiol Drug Saf 2020; 30:45-52. [PMID: 32964590 DOI: 10.1002/pds.5136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 09/02/2020] [Accepted: 09/09/2020] [Indexed: 11/07/2022]
Abstract
PURPOSE Identify if publication of the 2010 drug safety communication (DSC) regarding benzonatate was associated with a decrease in the incidence of severe benzonatate poisonings reported to United States poison centers. METHODS This retrospective database study utilized the National Poison Data System to compare the incidence of severe benzonatate poisonings before and after the publication of a drug safety communication. We utilized interrupted time series analysis to compare 2000-2010 (pre-DSC) to 2012-2019 (post-DSC). RESULTS There were 18 619 benzonatate exposures reported to US poison centers during the time period covered and 11 554 exposures were included. There was an increase in exposures throughout the time period. There was no difference in the incidence of severe outcomes in the two time periods. In the pre-DSC era, rates of severe outcomes increased by 0.4% per year followed by an immediate non-significant drop of 2.9% in incidence of severe outcomes (P = .15). Finally, the slope of severe outcomes in the post-DSC era showed an increase of 0.3% per year, which was not significantly different from the pre-DSC era (P = .78). CONCLUSION Publication of a Drug Safety Communication regarding the risks of benzonatate did not result in a decrease in the proportion of severe benzonatate poisoning reported to US poison centers. Deaths and other severe outcomes continued to occur at a similar rate after the publication.
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Affiliation(s)
- James B Leonard
- Maryland Poison Center, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Hyunuk Seung
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Wendy Klein-Schwartz
- Maryland Poison Center, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
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Abstract
OBJECTIVE This is a descriptive study evaluating fatal iatrogenic and in-hospital medication errors reported to United States poison centers. METHODS A retrospective evaluation of the National Poison Data System from 2000-2017 of all therapeutic errors with a scenario coded as iatrogenic/healthcare professional or occurring in a healthcare facility. Death abstracts were reviewed for details of the exposure and therapeutic error scenarios were recoded or added to the case as appropriate. Cases, where death was considered not related to the exposure, were excluded. Additionally, we created one additional scenario (rate-related) and one additional route of administration (intrathecal) to better describe the cases. RESULTS A total of 172 cases were evaluated. The majority of the patients were female (52.3%) with a median age of 58.5 years (range: 2 days to 96 years). The most commonly reported medication error was "other incorrect dose" (22.7%) followed by other/unknown error (15.1%). The route of exposure was primarily parenteral (54.9%), followed by ingestion (30.2%), then intrathecal (7.0%). The most common medications were cardiac drugs, chemotherapeutics, opioids, anticoagulants, and sedative-hypnotic/antipsychotics. CONCLUSIONS Iatrogenic and in-hospital medication errors have been studied extensively with goals to reduce their occurrence. Specific controls to prevent incorrect dosing routes, 10-fold overdoses, and incorrect intrathecal administration have been instituted. Despite interventions, all three of these therapeutic errors continued to occur in 2017, suggesting that more preventive controls should be instituted.
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Affiliation(s)
- James B Leonard
- Maryland Poison Center, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Faisal S Minhaj
- Maryland Poison Center, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Wendy Klein-Schwartz
- Maryland Poison Center, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA
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Abstract
Iron poisoning was a leading cause of pediatric morbidity and mortality. We sought to assess whether the removal of strict iron packaging requirements in 2003 resulted in an increase in iron-related morbidity and mortality in pediatric exposures. We performed a retrospective cohort study utilizing the National Poison Data System from 2000 to 2017. A total of 4110 exposures met inclusion criteria: 847 from before (2000-2003) and 3263 after removal of unit-dose package regulations (2004-2017). The incidence of any marker of severity (7.2% vs 3.8%; odds ratio = 0.51, 95% confidence interval = 0.37-0.69) and frequency of deferoxamine use were both higher in the early time period (2.6% vs 1.0%; odds ratio = 0.38, 95% confidence interval = 0.22-0.66). There was no difference in the frequency of key serious effects (acidosis, elevated transaminases, hypotension). Despite removal of iron packaging regulations in the United States, there continues to be a decrease in the incidence of severe iron exposures in children.
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Leonard JB, McFadden C, Feemster AA, Klein-Schwartz W. Analysis of iatrogenic and in-hospital medication errors reported to United States poison centers: a retrospective observational study. Drugs Ther Perspect 2020. [DOI: 10.1007/s40267-020-00723-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Leonard JB, Klein-Schwartz W. Characterization of intentional-abuse venlafaxine exposures reported to poison control centers in the United States. Am J Drug Alcohol Abuse 2019; 45:421-426. [PMID: 30973750 DOI: 10.1080/00952990.2019.1599382] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 03/19/2019] [Accepted: 03/21/2019] [Indexed: 06/09/2023]
Abstract
Background: Venlafaxine use to achieve an amphetamine-like high has been described but data regarding the epidemiology and clinical effects are sparse. Objectives: Describe the prevalence and toxicity of venlafaxine abuse reported to US poison control centers. Methods: This was a retrospective review of venlafaxine exposures reported to the National Poison Data System (NPDS) from 2000 to 2016. Inclusion criteria were: age 12 years and older, reason for exposure intentional-abuse, and either single-substance exposure or venlafaxine was the first substance. The primary outcome was prevalence of intentional-abuse of venlafaxine. Secondary outcomes characterized demographics, geographic distribution, toxicity, and outcomes. Results: Intentional-abuse accounted for 752 of 85,621 venlafaxine exposures. Overall prevalence was 87.8 intentional-abuse exposures/10,000 venlafaxine exposures reported to NPDS (range, 59.3-117.6/10,000). Prevalence decreased from 107/10,000 in 2000 to 59.3/10,000 in 2016. Median age was 23 years and 50% were female. Primary route was ingestion (90.8%) with 4.7% using venlafaxine via inhalation/intranasal insufflation, and 3.7% both routes. There were 227 venlafaxine-only exposures; 54.0% were treated/released from the emergency department, 20% were admitted for medical management, 9.0% to a psychiatric facility, and 17.0% managed at home. Known medical outcomes for single-substance exposures were: no effect (24.0%), minor (39.0%), moderate (33.0%), and major (4.0%); no deaths occurred. Most frequent clinical effects were tachycardia (33.9%), drowsiness (20.7%), and agitation (11.5%). Conclusion: The prevalence of venlafaxine abuse reported to poison control centers has decreased. Medical outcomes are usually not serious. Clinicians should be aware that non-medical use is possible but infrequently reported to poison control centers.
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Affiliation(s)
- James B Leonard
- a Maryland Poison Center, Department of Pharmacy Practice and Science , University of Maryland School of Pharmacy , Baltimore , MD , USA
| | - Wendy Klein-Schwartz
- a Maryland Poison Center, Department of Pharmacy Practice and Science , University of Maryland School of Pharmacy , Baltimore , MD , USA
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Bentur Y, Lurie Y, Cahana A, Bloom-Krasik A, Kovler N, Neuman G, Gurevych B, Sofer P, Klein-Schwartz W. Poisoning in Israel: Annual Report of the Israel Poison Information Center, 2017. Isr Med Assoc J 2019; 21:175-182. [PMID: 30905103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND The Israel Poison Information Center (IPIC), Rambam Health Care Campus, provides 24-hour telephone consultations on clinical toxicology and drug and reproductive toxicology. It participates in research, teaching and regulatory activities, and provides laboratory services. In 2014, nurse specialists in poison information joined the IPIC. OBJECTIVES To report the epidemiology of poison exposures in Israel. METHODS We present computerized queries and a descriptive analysis of the medical records database of the IPIC for 2017. RESULTS A total of 39,928 poison exposure cases were recorded, reflecting increases of 226.3% and 26.7% compared with 1995 and 2012, respectively. Children < 6 years of age were involved in 47.0% of cases; 80.4% of calls were made by the public and 17.8% by physicians; 74.2% of exposures were unintentional and 7.3% intentional. Pharmaceuticals were involved in 51.4% of cases, chemicals in 36.9%, bites and stings in 2.2%, and plants and mushrooms in 1.5%. Substances most frequently involved were analgesics, cleaning products, and antimicrobials. Clinical severity was moderate/major in 3.3%, mainly due to insecticides, drugs of abuse, and corrosives. Three fatalities were recorded (due to colchicine, organophosphates, and volatile substance inhalant abuse). CONCLUSIONS Poison exposures and poisonings have markedly increased in Israel, contributing substantially to morbidity. The IPIC prevented unnecessary referrals to emergency departments. Its database is a valuable national resource for collecting and monitoring poisoning exposure cases. It can be used as a real-time surveillance system for the benefit of public health. It is recommended that reporting to the IPIC become mandatory, and its activities adequately supported by national resources.
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Affiliation(s)
- Yedidia Bentur
- Israel Poison Information Center, Rambam Health Care Campus, affiliated with Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Yael Lurie
- Israel Poison Information Center, Rambam Health Care Campus, affiliated with Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Alfred Cahana
- Israel Poison Information Center, Rambam Health Care Campus, affiliated with Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Anna Bloom-Krasik
- Israel Poison Information Center, Rambam Health Care Campus, affiliated with Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Nona Kovler
- Israel Poison Information Center, Rambam Health Care Campus, affiliated with Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Gal Neuman
- Israel Poison Information Center, Rambam Health Care Campus, affiliated with Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Bella Gurevych
- Israel Poison Information Center, Rambam Health Care Campus, affiliated with Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Paul Sofer
- Israel Poison Information Center, Rambam Health Care Campus, affiliated with Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Wendy Klein-Schwartz
- Maryland Poison Center, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA
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Leonard JB, Klein-Schwartz W. Using a spare medication vial to store multiple medications: A potentially fatal in-home medication error. Am J Health Syst Pharm 2019; 76:264-265. [DOI: 10.1093/ajhp/zxy037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- James B Leonard
- Maryland Poison Center Department of Pharmacy Practice and Science University of Maryland School of Pharmacy Baltimore, MD
| | - Wendy Klein-Schwartz
- Maryland Poison Center Department of Pharmacy Practice and Science University of Maryland School of Pharmacy Baltimore, MD
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Leonard JB, Klein-Schwartz W. The others: characterizing "other" therapeutic errors reported to a poison center. Clin Toxicol (Phila) 2019; 57:652-656. [PMID: 30600728 DOI: 10.1080/15563650.2018.1538520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Background: Therapeutic errors are costly and result in unplanned hospital visits. Recent poison center studies on therapeutic errors have focused on coded data from either the National Poison Data System (NPDS) or individual poison centers. Approximately 21% of therapeutic errors reported to NPDS are coded as "other incorrect dose" (OI) or "other/unknown therapeutic error" (OU). The purpose of this study was to characterize errors coded as OI or OU reported to a single poison center. Methods: Retrospective, single poison center chart review was conducted of therapeutic error exposures with at least one scenario coded as OI or OU seen in or referred to hospitals from 1/1/2000 to 9/30/2017. Cases were reviewed and re-coded to predefined or newly created scenarios. Results: A total of 3413 cases were identified. There were 726 cases assessed as not therapeutic errors and re-coded as either intentional misuse (430), adverse reaction drug (204), or other non-therapeutic errors (82). Of the remaining cases, 1726 cases were re-coded to one of the 16 existing therapeutic error scenarios. After re-coding, there remained 971 coded as OI or OU. Most were due to double, triple, quadruple, or higher than recommended dose (477/971); an additional common error was mistaken strength (81/971). The remaining scenarios occurred in fewer than 50 cases each with greater than 40 different scenarios such that additional coded scenarios would not be feasible. Conclusions: Most cases coded as OI or OU could be recoded as one of the NPDS predefined therapeutic error scenarios or non-error reasons for exposure. Considering the large proportion of double dose cases and the unique errors associated with mistaken strengths of tablets, these scenarios could be appropriate to add as new predefined coding scenarios, which would aid in future research and patient counseling.
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Affiliation(s)
- James B Leonard
- a Department of Pharmacy Practice and Science, Maryland Poison Center , University of Maryland School of Pharmacy , Baltimore , MD , USA
| | - Wendy Klein-Schwartz
- a Department of Pharmacy Practice and Science, Maryland Poison Center , University of Maryland School of Pharmacy , Baltimore , MD , USA
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Leonard JB, Anderson B, Klein-Schwartz W. Does getting high hurt? Characterization of cases of LSD and psilocybin-containing mushroom exposures to national poison centers between 2000 and 2016. J Psychopharmacol 2018; 32:1286-1294. [PMID: 30182795 DOI: 10.1177/0269881118793086] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Lysergic acid diethylamide (LSD) and psilocybin are serotonergic hallucinogens that are used primarily for recreational abuse. Small studies evaluated the efficacy of LSD and psilocybin for several psychiatric conditions. There are limited safety or toxicity data for either of these substances, especially in large populations. METHODS This was a retrospective analysis of single-substance exposures of LSD or psilocybin-containing mushrooms (PcMs) reported to United States poison centers from 1 January 2000 to 31 December 2016. The study describes the most frequent toxicities, management sites, and medical outcomes. RESULTS A total of 5883 PcM and 3554 LSD exposures were included. Most patients were between 13 and 29 years of age (83.9% PcM, 88.9% LSD) and primarily male (77.9% PcM, 74.1% LSD). Most common clinical effects were hallucinations (45.8% PcM, 37.4% LSD), agitation (24.1% PcM, 42.4% LSD), and tachycardia (18.0% PcM, 38.6% LSD). Serious clinical effects were infrequent, but included hyperthermia, seizures, coma, increased serum creatinine, and cardiac arrest. Most patients were treated and released from the emergency department. More LSD patients were admitted to critical care and non-critical care units than PcM patients. Moderate effect was the most frequent outcome for both substances (61.0% PcM, 62.3% LSD). CONCLUSION These data find that LSD and PcM use occurs primarily in adolescents and young adults, who experience mild to moderate adverse effects. Serious effects are infrequent but can occur. While most LSD and PcM users require only emergency department management, LSD use is more likely to require medical admission.
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Affiliation(s)
- James B Leonard
- Maryland Poison Center, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Bruce Anderson
- Maryland Poison Center, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Wendy Klein-Schwartz
- Maryland Poison Center, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA
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Cordeiro SK, Daro RC, Seung H, Klein-Schwartz W, Kim HK. Evolution of clinical characteristics and outcomes of synthetic cannabinoid receptor agonist exposure in the United States: analysis of National Poison Data System data from 2010 to 2015. Addiction 2018; 113:1850-1861. [PMID: 29806885 DOI: 10.1111/add.14281] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Revised: 01/22/2018] [Accepted: 05/23/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND AND AIMS New synthetic cannabinoid receptor agonists (SCRAs) are synthesized each year to evade US governmental regulation and sold for recreational use. Our aim was to estimate the changes in the clinical effects and patient disposition associated with SCRA exposure from 2010 to 2015. DESIGN A retrospective observational cohort study. SETTING National Poison Data System that collects data on reports of poisonings from US poison centers. PARTICIPANTS A total of 19 388 isolated SCRA cases between 1 January 2010 and 31 December 2015 were identified. The mean age was 24.6 years and 77.8% were male. MEASUREMENTS Primary outcome was the change in the trend of patient disposition, i.e. treated and released versus hospitalization (e.g. non-critical care, critical care unit or psychiatry) between 2010 and 2015. Secondary outcomes included the trends in the clinical effects and their duration, and therapeutic interventions nationally and regionally. FINDINGS Reports of SCRA exposure peaked in 2011 (n = 5305) and 2015 (n = 5475). The majority of patients required supportive care and were treated and released from an emergency department. Hospitalization increased by annual percentage change in the log odds (APCO) of 21.0% (P < 0.0001) during the 6 years, with significant increases in admissions to critical care units and non-critical care units. Overall, tachycardia (32.1%), agitation/irritation (25.6%) and drowsiness/lethargy (20.4%) were the most frequently reported clinical effects from SCRA exposure. Clinical effects resolved within 2-8 hours in 52.8% of cases, but their duration increased markedly by 2015. Regionally, the largest number of SCRA cases was reported in the South (n = 9374, 48.6%). SCRA cases in the Northeast were hospitalized more frequently (27.4%), with cases in the Midwest being admitted more frequently to critical care units (15.3%). However, there were no significant differences in clinical toxicity or disposition among the regions. CONCLUSION Hospitalization resulting from toxicity from synthetic cannabinoid receptor agonists exposure in the United States increased significantly between 2010 and 2015.
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Affiliation(s)
- Samuel K Cordeiro
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ryan C Daro
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Hyunuk Seung
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Wendy Klein-Schwartz
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA.,Maryland Poison Center, Baltimore, MD, USA
| | - Hong K Kim
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.,Maryland Poison Center, Baltimore, MD, USA
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Abstract
AIM The number of cases reported to poison centers has decreased since 2008 but there is evidence that the complexity of calls is increasing. OBJECTIVES The objectives are to evaluate national poison center data for trends in reason and how these changes effect management site, medical outcomes, and poison center workload. METHODS Data regarding reason, age, management site, and medical outcome were extracted from annual reports of the National Poison Data System from 2000 to 2015. The proportion of cases by year were determined for unintentional and intentional exposures. Analysis of data from a single poison center from 2005 to 2015 compared the number of interactions between poison center staff and callers for unintentional versus intentional reasons. RESULTS Trend analyses found that from 2000 to 2015 the percent of unintentional cases decreased (from 85.9 to 78.4%, p < .0001) and the percent of intentional cases increased (from 11.3 to 17.6%, p < .0001). Age distribution changed with a decrease in children <13 years of age and increase in adolescents and adults. In these latter two age groups, the proportion due to intentional exposure increased while unintentional declined. The distribution of management sites changed over the 16-year period, with a decrease in non-HCF cases and significant increase in percent of cases treated in a HCF. The frequencies of moderate effect, major effect, and death were significantly higher for intentional exposures than for unintentional exposures. Analysis of data entry notes from a single center showed that the mean number of notes per unintentional case (1.61 ± 0.08) was significantly different from the mean number of notes per intentional case (9.23 ± 0.68) (p < .0001). DISCUSSION Poison centers are managing more intentional exposures and fewer unintentional exposures. Intentional exposures require more poison center staff expertise and time. CONCLUSION Looking only at poison center total call volume may not be an adequate method to gauge productivity.
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Affiliation(s)
- Bruce D Anderson
- a Department of Pharmacy Practice and Science , University of Maryland School of Pharmacy , Baltimore , MA , USA
| | - Hyunuk Seung
- a Department of Pharmacy Practice and Science , University of Maryland School of Pharmacy , Baltimore , MA , USA
| | - Wendy Klein-Schwartz
- a Department of Pharmacy Practice and Science , University of Maryland School of Pharmacy , Baltimore , MA , USA
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Biggs JM, Morgan JA, Lardieri AB, Kishk OA, Klein-Schwartz W. Abuse and Misuse of Selected Dietary Supplements Among Adolescents: a Look at Poison Center Data. J Pediatr Pharmacol Ther 2017; 22:385-393. [PMID: 29290737 DOI: 10.5863/1551-6776-22.6.385] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE The use of dietary supplements has increased and is associated with adverse effects. Indications for use include recreation, body image concerns, mood enhancement, or control of medical conditions. The risk of adverse effects may be enhanced if agents are used improperly. The objective of this study was to determine the frequency of abuse and misuse of 4 dietary substances among adolescents reported nationally to poison centers. Secondary outcomes included an assessment of medical outcomes, clinical effects, location of treatments provided, and treatments administered. METHODS This descriptive retrospective review assessed data concerning the use of garcinia (Garcinia cambogia), guarana (Paullinia cupana), salvia (Salvia divinorum), and St John's wort (Hypericum perforatum) among adolescents reported nationally to poison centers from 2003 to 2014. Adolescents with a singlesubstance exposure to one of the substances of interest coded as intentional abuse or misuse were included. Poison center calls for drug information or those with unrelated clinical effects were excluded. Data were collected from the National Poison Data System. RESULTS There were 84 cases: 7 cases of Garcinia cambogia, 28 Paullinia cupana, 23 Salvia divinorum, and 26 Hypericum perforatum. Garcinia cambogia was used more frequently by females (100% versus 0%), and Paullinia cupana and Salvia divinorum were used more frequently by males (61% versus 36% and 91% versus 9%, respectively). Abuse, driven by Salvia divinorum, was more common overall than misuse. Abuse was also more common among males than females (p <0.001). Use of these agents fluctuated over time. Overall, use trended down since 2010, except for Garcinia cambogia use. In 62 cases (73.8%), the medical outcome was minor or had no effect or was judged as nontoxic or minimally toxic. Clinical effects were most common with Paullinia cupana and Salvia divinorum. Treatment sites included emergency department (n = 33; 39.3%), non-healthcare facility (n = 24; 28.6%), admission to a health care facility (n = 8; 9.5%), and other/unknown (n = 19; 22.6%). CONCLUSIONS Abuse and misuse of these dietary supplements was uncommon, and outcomes were mild. Further research should be performed to determine use and outcomes of abuse/misuse of other dietary supplements in this population.
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Affiliation(s)
- Jessica M Biggs
- Department of Pharmacy (JMB, OAK), University of Maryland Medical Center, Baltimore, Maryland; Department of Pharmacy Practice and Science (JAM, ABL, WKS), University of Maryland School of Pharmacy, Baltimore, Maryland; and (WKS) Maryland Poison Center, Baltimore, Maryland
| | - Jill A Morgan
- Department of Pharmacy (JMB, OAK), University of Maryland Medical Center, Baltimore, Maryland; Department of Pharmacy Practice and Science (JAM, ABL, WKS), University of Maryland School of Pharmacy, Baltimore, Maryland; and (WKS) Maryland Poison Center, Baltimore, Maryland
| | - Allison B Lardieri
- Department of Pharmacy (JMB, OAK), University of Maryland Medical Center, Baltimore, Maryland; Department of Pharmacy Practice and Science (JAM, ABL, WKS), University of Maryland School of Pharmacy, Baltimore, Maryland; and (WKS) Maryland Poison Center, Baltimore, Maryland
| | - Omayma A Kishk
- Department of Pharmacy (JMB, OAK), University of Maryland Medical Center, Baltimore, Maryland; Department of Pharmacy Practice and Science (JAM, ABL, WKS), University of Maryland School of Pharmacy, Baltimore, Maryland; and (WKS) Maryland Poison Center, Baltimore, Maryland
| | - Wendy Klein-Schwartz
- Department of Pharmacy (JMB, OAK), University of Maryland Medical Center, Baltimore, Maryland; Department of Pharmacy Practice and Science (JAM, ABL, WKS), University of Maryland School of Pharmacy, Baltimore, Maryland; and (WKS) Maryland Poison Center, Baltimore, Maryland
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Abstract
CONTEXT Asenapine, iloperidone and lurasidone are relatively new atypical antipsychotics. There is limited information on toxicity on pediatric exposures to these drugs. The objective of this study was to compare toxicity associated with asenapine, iloperidone and lurasidone exposures in young children. METHODS A retrospective study of U.S. National Poison Data System from 2010 to 2015 of single substance exposures to asenapine, iloperidone or lurasidone in children <6 years of age that were followed to known outcome was performed. RESULTS There were 95 asenapine, 64 iloperidone and 124 lurasidone cases that met inclusion criteria. Reason was exploratory for 96% of cases. Drowsiness/lethargy occurred most frequently with iloperidone (45%) and least often with lurasidone (8%). Two iloperidone cases had respiratory depression. For asenapine, iloperidone and lurasidone, respectively, management sites were on-site non-health care facility (non-HCF) (32%, 16%, 26%), treated/discharged from emergency department (ED) (46%, 47%, 63%), admitted to noncritical care (9%, 14%, 10%) and admitted to critical care (10%, 22%, 2%). Clinical effect duration was 8 h or less for the majority of non-HCF cases (80%) and for children treated/discharged from the ED (72%). For asenapine, iloperidone and lurasidone, coded outcomes were no effect (50%, 41%, 81%), minor effect (43%, 39%, 17%), moderate (6%, 19%, 2%) and major (0, 2%, 0). DISCUSSION AND CONCLUSIONS These findings suggest that in children under 6 years of age, lurasidone exposures were least serious and iloperidone exposures were most serious based on clinical effects, management sites and coded outcomes. Observation of symptomatic children in the ED for 8 h should be sufficient to make triage decisions based on persistence or resolution of clinical effects.
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Affiliation(s)
- Gina Stassinos
- a Maryland Poison Center, Department of Pharmacy Practice and Science , University of Maryland School of Pharmacy , Baltimore , MD , USA
| | - Wendy Klein-Schwartz
- a Maryland Poison Center, Department of Pharmacy Practice and Science , University of Maryland School of Pharmacy , Baltimore , MD , USA
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Desrochers J, Wojciechowski J, Klein-Schwartz W, Gobburu JVS, Gopalakrishnan M. Bayesian Forecasting Tool to Predict the Need for Antidote in Acute Acetaminophen Overdose. Pharmacotherapy 2017; 37:916-926. [PMID: 28609563 DOI: 10.1002/phar.1972] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
STUDY OBJECTIVE Acetaminophen (APAP) overdose is the leading cause of acute liver injury in the United States. Patients with elevated plasma acetaminophen concentrations (PACs) require hepatoprotective treatment with N-acetylcysteine (NAC). These patients have been primarily risk-stratified using the Rumack-Matthew nomogram. Previous studies of acute APAP overdoses found that the nomogram failed to accurately predict the need for the antidote. The objectives of this study were to develop a population pharmacokinetic (PK) model for APAP following acute overdose and evaluate the utility of population PK model-based Bayesian forecasting in NAC administration decisions. DESIGN, PATIENTS AND MEASUREMENTS Limited APAP concentrations from a retrospective cohort of acute overdosed subjects from the Maryland Poison Center were used to develop the population PK model and to investigate the effect of type of APAP products and other prognostic factors. The externally validated population PK model was used a prior for Bayesian forecasting to predict the individual PK profile when one or two observed PACs were available. The utility of Bayesian forecasted APAP concentration-time profiles inferred from one (first) or two (first and second) PAC observations were also tested in their ability to predict the observed NAC decisions. MAIN RESULTS A one-compartment model with first-order absorption and elimination adequately described the data with single activated charcoal and APAP products as significant covariates on absorption and bioavailability. The Bayesian forecasted individual concentration-time profiles had acceptable bias (6.2% and 9.8%) and accuracy (40.5% and 41.9%) when either one or two PACs were considered, respectively. The sensitivity and negative predictive value of the Bayesian forecasted NAC decisions using one PAC were 84% and 92.6%, respectively. CONCLUSION The population PK analysis provided a platform for acceptably predicting an individual's concentration-time profile following acute APAP overdose with at least one PAC, and the individual's covariate profile, and can potentially be used for making early NAC administration decisions.
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Affiliation(s)
- Julie Desrochers
- Center for Translational Medicine, University of Maryland School of Pharmacy, Baltimore, Maryland.,inVentiv Health, Burlington, Ontario, Canada
| | - Jessica Wojciechowski
- Australian Centre for Pharmacometrics, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia, Australia
| | - Wendy Klein-Schwartz
- Maryland Poison Center, University of Maryland School of Pharmacy, Baltimore, Maryland
| | - Jogarao V S Gobburu
- Center for Translational Medicine, University of Maryland School of Pharmacy, Baltimore, Maryland
| | - Mathangi Gopalakrishnan
- Center for Translational Medicine, University of Maryland School of Pharmacy, Baltimore, Maryland
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Whittaker CF, Tom SE, Bivens A, Klein-Schwartz W. Evaluation of an Educational Intervention on Knowledge and Awareness of Medication Safety in Older Adults with Low Health Literacy. American Journal of Health Education 2017. [DOI: 10.1080/19325037.2016.1271754] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Chanel F. Whittaker
- University of Maryland School of Pharmacy
- Peter Lamy Center on Drug Therapy and Aging
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Sera L, Brown M, McPherson ML, Walker KA, Klein-Schwartz W. State survey of medical boards regarding abrupt loss of a prescriber of controlled substances. J Opioid Manag 2017; 13:105-110. [PMID: 28829525 DOI: 10.5055/jom.2017.0374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVES The purpose of the study was to evaluate states' experiences with abrupt changes in controlled substances (CS) prescribing, to determine whether states have action plans in place to manage such situations, and describe the components of any such plans. METHODS A survey of executive directors of 51 medical boards was conducted to evaluate states' experiences with abrupt changes in CS prescribing, the extent of consumer complaints attributed to these events, and the types of plans in place to manage these situations. RESULTS Forty-six executive directors of medical boards responded. Twenty boards (43.5 percent) confirmed that their state had experienced abrupt loss of CS providers and 11 (55 percent) of these executive directors indicated that the loss resulted in increased consumer complaints. The majority of executive directors (86 percent) had no action plan. Six executive directors reported some type of action plan or process consisting of regulatory action, patient-provider connection, professional education, patient education, or public notice. CONCLUSIONS Most states do not have operational plans in place. However, a few have key strategies that may be useful in addressing potential problems following abrupt loss of a CS prescriber. State medical boards can play a significant role in the development of comprehensive preparedness plans to mitigate damage from the loss of CS prescribers in the community.
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Affiliation(s)
- Leah Sera
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland
| | - Micke Brown
- Community Nurse, Washington County Health Department, Baltimore, Maryland
| | - Mary Lynn McPherson
- Professor, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland
| | - Kathryn A Walker
- Associate Professor, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland
| | - Wendy Klein-Schwartz
- Professor Emeritus, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland
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Abstract
CONTEXT The rise in atypical antipsychotic prescribing increases the risk of pediatric exposures. Published studies in children are limited. OBJECTIVE The objectives are to evaluate national poison center data on atypical antipsychotic exposures in young children and compare toxicity amongst selected agents. MATERIALS AND METHODS A retrospective study of U.S. National Poison Data System single substance exposures, from 2005 to 2013, of five atypical antipsychotics in children <6 years old, followed to known outcome was performed. Data were evaluated for reason, clinical effects, management site and outcome. RESULTS There were 16,935 exposures included: 5018 aripiprazole, 1735 olanzapine, 3904 quetiapine, 4778 risperidone and 1500 ziprasidone. Median age was two years. Most common reason was unintentional-general (90.6%). Therapeutic error occurred more often with risperidone (19.9%). Clinical effects occurred in 59.4% of aripiprazole, 57.9% of olanzapine, 56.6% of ziprasidone, 40.1% of risperidone, and 29.3% of quetiapine. The most frequent were drowsiness/lethargy (35.6%), tachycardia (6.9%), agitation (4.0%), and ataxia (3.3%). Drowsiness/lethargy occurred most with aripiprazole (47.6%), ziprasidone (46.5%) and olanzapine (45.1%) and least with quetiapine (20.5%) and risperidone (28.6%). Tachycardia and agitation both occurred most often with olanzapine (11.4% and 12.7%, respectively). Management sites were non-health care facility (28.0%), treated/discharged from emergency department (48.9%), admitted - noncritical care (11.4%), critical care (9.5%), and other/unknown (2.2%). Admission was lowest for risperidone (13.9%) and quetiapine (11.9%) and highest for olanzapine (32.9%). Coded outcomes were no effect (53.3%), minor (33.7%), moderate (12.1%), major (0.9%) and no deaths. Moderate/major outcomes occurred most often with ziprasidone (20.5%) and olanzapine (19.0%) and least often with quetiapine (5.3%) and risperidone (10.9%). DISCUSSION AND CONCLUSION Overall outcomes were favorable, with major toxicity in <1% of exposures. Risperidone and quetiapine exposures resulted in less toxicity. This finding may be attributed to higher frequency of therapeutic errors for risperidone but the reason for less toxicity with quetiapine is unclear.
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Affiliation(s)
- Gina Stassinos
- a Maryland Poison Center, Department of Pharmacy Practice and Science , University of Maryland School of Pharmacy , Baltimore , MD , USA
| | - Wendy Klein-Schwartz
- a Maryland Poison Center, Department of Pharmacy Practice and Science , University of Maryland School of Pharmacy , Baltimore , MD , USA
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24
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Abstract
The risk of toxicity in a child who is unintentionally exposed to a beta-blocking drug remains uncertain. The current study further defines this risk, particularly in the common scenario of ingestion of one or two tablets. A prospective cohort of 208 pediatric patients, 6 months to 6 years of age, reported to two regional poison centers serves as the study population. Data were collected with a standardized instrument during the care of each patient and for a minimum of 24 hours after exposure. No instances of serious toxicity typical of beta-blocker intoxication, such as ‘shock-like’ states, arrhythmias or seizures were observed in this series. Furthermore, there were no reported episodes of hypoglycemia, symptomatic bradycardia or bronchospasm. Nine instances of altered mental status or behavioral changes were reported. All appeared to be minor in nature. The most serious outcome was charcoal aspiration during gastrointestinal decontamination. This study adds to a growing body of evidence suggesting that exposure to one or two beta-blocker tablets places children at very little, if any, risk of toxicity.
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Affiliation(s)
- J N Love
- Department of Emergency Medicine, Georgetown University Hospital, Ground Floor CCC bldg, 3800 Reservoir Rd, NW, Washington, DC 20007, USA.
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25
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Klein-Schwartz W, Stassinos GL, Isbister GK. Treatment of sulfonylurea and insulin overdose. Br J Clin Pharmacol 2016; 81:496-504. [PMID: 26551662 DOI: 10.1111/bcp.12822] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 11/02/2015] [Accepted: 11/03/2015] [Indexed: 11/26/2022] Open
Abstract
The most common toxicity associated with sulfonylureas and insulin is hypoglycaemia. The article reviews existing evidence to better guide hypoglycaemia management. Sulfonylureas and insulin have narrow therapeutic indices. Small doses can cause hypoglycaemia, which may be delayed and persistent. All children and adults with intentional overdoses need to be referred for medical assessment and treatment. Unintentional supratherapeutic ingestions can be initially managed at home but if symptomatic or if there is persistent hypoglycaemia require medical referral. Patients often require intensive care and prolonged observation periods. Blood glucose concentrations should be assessed frequently. Asymptomatic children with unintentional sulfonylurea ingestions should be observed for 12 h, except if this would lead to discharge at night when they should be kept until the morning. Prophylactic intravenous dextrose is not recommended. The goal of therapy is to restore and maintain euglycaemia for the duration of the drug's toxic effect. Enteral feeding is recommended in patients who are alert and able to tolerate oral intake. Once insulin or sulfonylurea-induced hypoglycaemia has developed, it should be initially treated with an intravenous dextrose bolus. Following this the mainstay of therapy for insulin-induced hypoglycaemia is intravenous dextrose infusion to maintain the blood glucose concentration between 5.5 and 11 mmol l(-1) . After sulfonylurea-induced hypoglycaemia is initially corrected with intravenous dextrose, the main treatment is octreotide which is administered to prevent insulin secretion and maintain euglycaemia. The observation period varies depending on drug, product formulation and dose. A general guideline is to observe for 12 h after discontinuation of intravenous dextrose and, if applicable, octreotide.
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Affiliation(s)
- Wendy Klein-Schwartz
- Maryland Poison Center, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, USA
| | - Gina L Stassinos
- Maryland Poison Center, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, USA
| | - Geoffrey K Isbister
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, Australia
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26
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Azab SMS, Hirshon JM, Hirshon JM, Hayes BD, El-Setouhy M, Smith GS, Sakr ML, Tawfik H, Klein-Schwartz W. Epidemiology of acute poisoning in children presenting to the poisoning treatment center at Ain Shams University in Cairo, Egypt, 2009-2013. Clin Toxicol (Phila) 2016; 54:20-6. [PMID: 26653953 PMCID: PMC4933840 DOI: 10.3109/15563650.2015.1112014] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Pediatric poisonings represent a major and preventable cause of morbidity and mortality throughout the world. Epidemiologic information about poisoning among children in many lower- and middle-income countries is scarce. This study describes the epidemiology of acute poisonings in children presenting to Ain Shams University's Poisoning Treatment Center (ASU-PTC) in Cairo and determines the causative agents and characteristics of acute poisoning in several pediatric age groups. METHODS This retrospective study involved acutely poisoned patients, 0-18 years of age, who presented to the ASU-PTC between 1 January 2009 and 31 December 2013. Data were extracted from electronic records maintained by the ASU-PTC. Collected data included demographics, substance of exposure, circumstances of the poisoning, patient disposition, and outcome. RESULTS During the 5-year study period, 38 470 patients meeting our criteria were treated by the ASU-PTC; 19 987 (52%) were younger than 6 years of age; 4196 (11%) were 6-12 years; and 14 287 (37%) were >12 years. Unintentional poisoning accounted for 68.5% of the ingestions, though among adolescents 84.1% of ingestions were with self-harm intent. In all age groups, the most frequent causative drugs were non-opioid analgesics, antipyretics, and antirheumatics. The most common nonpharmaceutical agents were corrosives in preschool children and pesticides in adolescents. Most patients had no/minor effects (29 174 [75.8%]); hospitalization rates were highest among adolescents. There were 119 deaths (case fatality rate of 0.3), primarily from pesticide ingestion. CONCLUSION Poisoning in preschool children is mainly unintentional and commonly due to nonpharmaceutical agents whereas poisoning in adolescents is mainly intentional (self-harm). Pesticides, mainly organophosphorous compounds and carbamates, were the most frequent agents leading to morbidity and mortality.
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Affiliation(s)
- Sonya M S Azab
- a Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine , Ain Shams University , Cairo , Egypt
| | | | - John Mark Hirshon
- b Department of Emergency Medicine , University of Maryland School of Medicine , Baltimore , MD , USA
- c Charles McC. Mathias. Jr. National Study Center for Trauma and EMS , University of Maryland School of Medicine , Baltimore , MD , USA
| | - Bryan D Hayes
- d Department of Pharmacy Services , University of Maryland Medical Center , Baltimore , MD , USA
| | - Maged El-Setouhy
- e Department of Community , Environmental and Occupational Medicine, Faculty of Medicine, Ain Shams University , Cairo , Egypt
- f Substance Abuse Research Center, Jazan University , Jazan , Saudi Arabia
| | - Gordon S Smith
- g Department of Pharmacy Practice and Science , Maryland Poison Center, University of Maryland School of Pharmacy , Baltimore , MD , USA
| | - Mahmoud Lotfy Sakr
- a Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine , Ain Shams University , Cairo , Egypt
- h Poisoning Treatment Center, Ain Shams University Hospitals , Cairo , Egypt
| | - Hany Tawfik
- h Poisoning Treatment Center, Ain Shams University Hospitals , Cairo , Egypt
| | - Wendy Klein-Schwartz
- i Maryland Poison Center, University of Maryland School of Pharmacy , Baltimore , MD , USA
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Spiller HA, Mowry JB, Aleguas A, Griffith JRK, Goetz R, Ryan ML, Bangh S, Klein-Schwartz W, Schaeffer S, Casavant MJ. An Observational Study of the Factor Xa Inhibitors Rivaroxaban and Apixaban as Reported to Eight Poison Centers. Ann Emerg Med 2015; 67:189-95. [PMID: 26298448 DOI: 10.1016/j.annemergmed.2015.07.014] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 06/29/2015] [Accepted: 07/07/2015] [Indexed: 12/17/2022]
Abstract
STUDY OBJECTIVE Rivaroxaban and apixaban are part of a new group of oral anticoagulants targeting factor Xa and approved by the Food and Drug Administration in 2011 and 2012. These oral anticoagulants are administered at fixed daily doses, without the need for laboratory-guided adjustments. There are limited data available on supratherapeutic doses or overdose of the oral Xa inhibitors. This study characterizes the clinical effect in patients exposed to rivaroxaban and apixaban. METHODS A retrospective study collected data from 8 regional poison centers covering 9 states. Cases were initially identified by a search of the poison centers' databases for case mentions involving a human exposure to Xarelto, rivaroxaban, Eliquis, or apixaban. Inclusion criteria included single-substance exposure. Exclusion criteria were animal exposure, polysubstance exposure, or information call. Data for the study were collected by individual chart review, including case narratives, and compiled into a single data set. RESULTS There were 223 patients: 124 (56%) were female patients, mean age was 60 years, and 20 were children younger than 12 years (9%). One hundred ninety-eight patients ingested rivaroxaban (89%) and 25 ingested apixaban (11%). Dose was reported in 182 rivaroxaban patients, with a mean dose of 64.5 mg (range 15 to 1,200 mg), and in 21 apixaban patients, with a mean dose of 9.6 mg (range 2.5 to 20 mg). For rivaroxaban, prothrombin time was measured in 49 patients (25%) and elevated in 7; partial thromboplastin time, measured in 49 (25%) and elevated in 5; and international normalized ratio, measured in 61 (31%) and elevated in 13. For apixaban, prothrombin time was measured in 6 patients (24%) and elevated in none; partial thromboplastin time, measure in 6 (24%) and elevated in none; and international normalized ratio, measured in 5 patients (20%) and elevated in none. Bleeding was reported in 15 patients (7%): 11 rivaroxaban and 4 apixaban. The site of bleeding was gastrointestinal (8), oral (2), nose (1), bruising (1), urine (1), and subdural (1). The subdural bleeding occurred after fall and head injury. All cases with bleeding involved long-term ingestions. Coagulation test results were normal in most patients with bleeding: prothrombin time 5 of 6 (83%), partial thromboplastin time 5 of 6 (83%), and international normalized ratio 5 of 9 (55%). Blood products were used in 7 rivaroxaban patients (1 suicide) and 3 apixaban patients. No bleeding or altered coagulation test results occurred in children, which all involved a one-time ingestion. All 12 suicide attempts involved rivaroxaban: altered coagulation test results occurred for 5 patients (42%), no bleeding occurred in any suicide attempt patient, 1 patient was treated with fresh frozen plasma (international normalized ratio 12.47), and dose by patient history did not predict risk of altered coagulation or bleeding. Two rivaroxaban patients experienced elevation of hepatic transaminase levels greater than 1,000 U/L. CONCLUSION Bleeding after Xa inhibitor ingestion as a single agent is uncommon. Prothrombin time, partial thromboplastin time, or international normalized ratio may be elevated in a minority of cases but appears unreliable to measure risk of bleeding. Massive acute ingestion in suicide attempt may result in significant anticoagulation. Single exploratory ingestion by children was not associated with toxicity.
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Affiliation(s)
- Henry A Spiller
- Central Ohio Poison Center, Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, Ohio State University College of Medicine, Columbus, OH.
| | - James B Mowry
- Indiana Poison Center, Indiana University Health Methodist Hospital, and the Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Alfred Aleguas
- Florida Poison Information Center-Tampa, Tampa General Hospital, Tampa, FL
| | - Jill R K Griffith
- College of Pharmacy, Ohio State University, Columbus, OH; Mount Carmel Medical Center West, Columbus, OH
| | - Robert Goetz
- Cincinnati Drug & Poison Information Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | | | - Stacey Bangh
- Minnesota Poison Control System, Hennepin County Medical System, Minneapolis, MN
| | - Wendy Klein-Schwartz
- Maryland Poison Center and the University of Maryland School of Pharmacy, Baltimore, MD
| | - Scott Schaeffer
- Oklahoma Center for Poison & Drug Information, Oklahoma City, OK
| | - Marcel J Casavant
- Central Ohio Poison Center, Nationwide Children's Hospital, Columbus, OH; College of Pharmacy, Ohio State University, Columbus, OH; Ohio State University College of Medicine, Columbus, OH
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Kaland ME, Klein-Schwartz W, Anderson BD. Toxalbumin exposures: 12 years' experience of U.S. poison centers. Toxicon 2015; 99:125-9. [PMID: 25817002 DOI: 10.1016/j.toxicon.2015.03.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 03/19/2015] [Accepted: 03/25/2015] [Indexed: 11/20/2022]
Abstract
BACKGROUND Toxalbumins are natural plant toxins purported to be highly toxic. The purpose was to evaluate toxalbumin exposures reported to U.S. poison centers to determine plants involved and their toxicities. METHODS A retrospective review of National Poison Data System data on acute toxalbumin exposures with known outcomes from 2000 through 2011 was performed. RESULTS There were 1164 exposures. The majority involved one route (1135; 97.5%), mostly ingestions (904; 79.7%) or dermal (166; 14.3%). Most patients developed no effects (694; 59.6%) or minor effects (374; 32.1%). Moderate or major effects occurred in 8.3% with 66.6% ingestions and 23.9% dermal. There were no deaths. Exposures to the plants Ricinus communis and Robinia pseudoacacia were most common (33.8% and 32.9%, respectively), with gastrointestinal effects from R. communis (vomiting 19.6%, diarrhea 8.9%, nausea 7.9%) and dermal effects from R. pseudoacacia (puncture 28.7%, dermal irritation/pain 27.9%, and edema 13.3%). CONCLUSIONS While toxalbumin plant exposures were generally well-tolerated, continued evaluation of risk is warranted since plants were primarily identified by the public. Major effects occurred in under 1% of cases overall, and not at all following unintentional ingestions. These findings should help allay concerns that unintentional ingestions of toxalbumin plants by young children will cause serious toxicity and possibly death.
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Affiliation(s)
| | | | - Bruce D Anderson
- Maryland Poison Center, University of Maryland School of Pharmacy, USA
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Kaland ME, Klein-Schwartz W. Comparison of lisdexamfetamine and dextroamphetamine exposures reported to U.S. poison centers. Clin Toxicol (Phila) 2015; 53:477-85. [DOI: 10.3109/15563650.2015.1027903] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Bentur Y, Lurie Y, Cahana A, Kovler N, Bloom-Krasik A, Gurevych B, Klein-Schwartz W. Poisoning in Israel: annual report of the Israel Poison Information Center, 2012. Isr Med Assoc J 2014; 16:686-692. [PMID: 25558696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND The Israel National Poison Information Center (IPIC), Rambam Health Care Campus, provides 24 hour telephone consultations in clinical toxicology as well as drug and teratogen information. It participates in research, teaching and regulatory activities, and also provides laboratory services. OBJECTIVES To report data on the epidemiology of poisonings and poison exposures in Israel. METHODS We made computerized queries and descriptive analyses of the medical records database of the IPIC during 2012. RESULTS A total of 31,519 poison exposure cases were recorded, a 157.6% increase compared with 1995. Children < 6 years of age were involved in 43.1% of cases; 74.0% of calls were made by the public and 23.7% by physicians; 74.8% of exposures were unintentional and 9.1% intentional. Chemicals were involved in 35.8% of all cases (single and multiple substances), pharmaceuticals in 48.8%, bites and stings in 3.8%, and plants and mushrooms in 1.6%. Substances most frequently involved were analgesics, cleaning products and antimicrobials. Clinical severity was moderate/major in 3.4%. Substances most frequently involved in moderate/major exposures were corrosives, insecticides and snake venom. Four fatalities were recorded; all were intentional exposures in adults (corrosive, medications, energy drink). CONCLUSIONS Poison exposures and poisonings have increased significantly and have contributed substantially to morbidity and mortality in Israel. The IPIC database is a valuable national resource for the collection and monitoring of poisoning exposure cases. It can be used as a real-time surveillance system for the benefit of public health. It is recommended that reporting to the IPIC become mandatory and its activities be adequately supported by national resources.
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Affiliation(s)
- Yedidia Bentur
- Rambam Health Care Campus, affiliated with Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.
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Tsay ME, Klein-Schwartz W, Anderson B. Toxicity and clinical outcomes of paliperidone exposures reported to U.S. Poison Centers. Clin Toxicol (Phila) 2014; 52:207-13. [DOI: 10.3109/15563650.2014.882000] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Doyon S, Klein-Schwartz W, Lee S, Beuhler MC. Fatalities involving acetaminophen combination products reported to United States poison centers. Clin Toxicol (Phila) 2013; 51:941-8. [DOI: 10.3109/15563650.2013.848282] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Lee S, Klein-Schwartz W, Welsh C, Doyon S. Medical Outcomes Associated with Nonmedical Use of Methadone and Buprenorphine. J Emerg Med 2013; 45:199-205. [DOI: 10.1016/j.jemermed.2012.11.104] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Revised: 06/18/2012] [Accepted: 11/06/2012] [Indexed: 11/26/2022]
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Doyon S, Klein-Schwartz W, Anderson BA, Welsh C. A Novel Approach to Informing the Public about the Risks of Overdose and Nonmedical Use of Prescription Medications. Am J Addict 2013; 22:108-12. [DOI: 10.1111/j.1521-0391.2013.00305.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2011] [Revised: 08/17/2011] [Accepted: 11/01/2011] [Indexed: 11/27/2022] Open
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Klein-Schwartz W, Benson BE, Lee SC, Litovitz T. Comparison of citalopram and other selective serotonin reuptake inhibitor ingestions in children. Clin Toxicol (Phila) 2012; 50:418-23. [DOI: 10.3109/15563650.2012.678497] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Klein-Schwartz W. Book Review: Clarke's Analysis of Drugs and Poisons, 4th Edition. Ann Pharmacother 2012. [DOI: 10.1345/aph.1q427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Wendy Klein-Schwartz
- Coordinator of Research and Education, Maryland Poison Center; Associate Professor, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD
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Abstract
OBJECTIVES This study sought to determine whether an increase in therapeutic errors involving prescription cough and cold medications (CCM) reported to poison centers was observed following the October 2007 voluntary withdrawal of over-the-counter CCM. METHODS Analysis of therapeutic errors involving prescription CCM in children under 2 years of age for the 33 months before and the 27 months after the October 2007 withdrawal. RESULTS Total counts of therapeutic errors involving prescription CCM in children under 2 years of age decreased from 452 to 337 per year. Rates of therapeutic errors decreased from 0.43 cases/100,000 person-month prewithdrawal to 0.32 postwithdrawal, a 25.6% decrease (p<0.0001). CONCLUSIONS An increase in harm as measured by the number of poison center calls for therapeutic errors involving prescription CCM was not observed in the 27-month time period after the withdrawal. A significant decrease in therapeutic errors involving these products is reported.
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Affiliation(s)
- Suzanne Doyon
- University of Maryland School of Pharmacy, Maryland Poison Center, Baltimore, Maryland
| | - Yolande Tra
- University of Maryland School of Pharmacy, Maryland Poison Center, Baltimore, Maryland
| | - Wendy Klein-Schwartz
- University of Maryland School of Pharmacy, Maryland Poison Center, Baltimore, Maryland
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Dougherty PP, Klein-Schwartz W. Unexpected late rise in plasma acetaminophen concentrations with change in risk stratification in acute acetaminophen overdoses. J Emerg Med 2011; 43:58-63. [PMID: 21719230 DOI: 10.1016/j.jemermed.2011.05.023] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2010] [Revised: 11/02/2010] [Accepted: 05/23/2011] [Indexed: 12/22/2022]
Abstract
BACKGROUND The acetaminophen risk analysis nomogram is used to predict hepatotoxicity risk in acute acetaminophen overdose based on a single plasma acetaminophen concentration (PAC) measured between 4 and 24 h after ingestion. There are case reports of patients with acute overdoses of acetaminophen combination products in whom a toxic PAC occurred later after an initial non-toxic PAC at approximately 4 h. OBJECTIVES The objective was to describe patients who had an initial non-toxic PAC and a subsequent toxic PAC. METHODS A poison center's database was searched for records in which patients were administered N-acetylcysteine. Cases were included if they involved an acute overdose of an acetaminophen-containing product with at least 2 plottable PACs, the first of which was obtained at least 4 h after ingestion and was below the treatment line on the nomogram with a subsequent toxic PAC. Data were analyzed for doses, timed PACs, specific acetaminophen preparation, coingestants, activated charcoal administration, and clinical effects. RESULTS Twenty patients were included. Thirteen patients ingested combination products. All patients experienced vomiting, neurologic, or cardiovascular effects at presentation or before obtaining the second PAC. Two patients developed hepatotoxicity, one of which died from the complications of acetaminophen-induced hepatotoxicity. CONCLUSION The nomogram fails to predict toxicity based on a single PAC in a small subset of patients.
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Affiliation(s)
- Patrick P Dougherty
- Clinical Toxicology, University of Maryland School of Pharmacy, Maryland Poison Center, Baltimore, Maryland, USA
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Klein-Schwartz W, Sorkin JD, Doyon S. Impact of the voluntary withdrawal of over-the-counter cough and cold medications on pediatric ingestions reported to poison centers. Pharmacoepidemiol Drug Saf 2011; 19:819-24. [PMID: 20533537 DOI: 10.1002/pds.1971] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
PURPOSE To assess the impact of a voluntary withdrawal of over-the-counter cough and cold medications (OTC CCMs) labeled for children under age 2 years on pediatric ingestions reported to the American Association of Poison Control Centers. METHODS Trend analysis of OTC CCMs ingestions in children under the age 6 years resulting from therapeutic errors or unintentional poisonings for 27 months before (pre-) and 15 months after (post-) the October 2007 voluntary withdrawal was conducted. The rates and outcome severity were examined. RESULTS The mean annual rate of therapeutic errors involving OTC CCMs post-withdrawal, in children less than 2-years of age, 45.2/100,000 (95%CI 30.7-66.6) was 54% of the rate pre-withdrawal, 83.8/100,000 (95%CI 67.6-104.0). The decrease was statistically significant p < 0.02. In this age group, there was no difference in the frequency of severe outcomes resulting from therapeutic errors post-withdrawal. There was no significant difference in unintentional poisoning rates post-withdrawal 82.1/100,000 (66.0-102.2) vs. pre-withdrawal 98.3/100,000 (84.4-114.3) (p < 0.21) in children less than 2-years of age. There were no significant reductions in rates of therapeutic errors and unintentional poisonings in children ages 2-5 years, who were not targeted by the withdrawal. CONCLUSIONS A significant decrease in annual rates of therapeutic errors in children under 2-years reported to Poison Centers followed the voluntary withdrawal of OTC CCMs for children under age 2-years. Concerns that withdrawal of pediatric medications would paradoxically increase poisonings from parents giving products intended for older age groups to young children are not supported.
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Affiliation(s)
- Wendy Klein-Schwartz
- Maryland Poison Center, University of Maryland School of Pharmacy, Baltimore, MD, USA.
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Abstract
The objective is to evaluate the evidence regarding octreotide's efficacy as a treatment for sulfonylurea-induced hypoglycemia. A search of PubMed for articles published from 1965 to 2008 using combinations of the terms octreotide, antidote, sulfonylurea, overdose, poisoning, and toxicity was performed. References from identified articles were reviewed for additional sources. Animal studies, case reports, case series, and randomized controlled trials were evaluated. An animal model of sulfonylurea overdose demonstrates that octreotide reduces the number of refractory sulfonylurea-induced hypoglycemic episodes. Published case reports describe the use of octreotide to prevent recurrent hypoglycemia after sulfonylurea overdose. A retrospective case series demonstrates that administration of octreotide decreases the need for supplemental dextrose boluses as well as hypoglycemic events. Two prospective, controlled trials determined that octreotide and supplemental dextrose increase blood glucose concentrations with fewer hypoglycemic events. Based on animal and human data, there is sufficient evidence to recommend the use of octreotide with supplemental dextrose for the treatment of sulfonylurea-induced hypoglycemia.
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Affiliation(s)
- Patrick P Dougherty
- Maryland Poison Center, University of Maryland School of Pharmacy, Baltimore, MD 21201, USA.
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Benson BE, Farooqi MF, Klein-Schwartz W, Litovitz T, Webb AN, Borys DJ, Lung D, Rutherfoord Rose S, Aleguas A, Sollee DR, Seifert SA. Diphenhydramine dose–response: a novel approach to determine triage thresholds. Clin Toxicol (Phila) 2010; 48:820-31. [DOI: 10.3109/15563650.2010.514269] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Klein-Schwartz W, Doyon S, Dowling T. Drug Adsorption Efficacy and Palatability of a Novel Charcoal Cookie Formulation. Pharmacotherapy 2010; 30:888-94. [DOI: 10.1592/phco.30.9.888] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Anderson B, Ke X, Klein-Schwartz W. Potential for erroneous interpretation of poisoning outcomes due to changes in National Poison Data System reporting. Clin Toxicol (Phila) 2010; 48:745-9. [DOI: 10.3109/15563650.2010.502122] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Hayes BD, Klein-Schwartz W. Consistency between coded poison center data and fatality abstract narratives for therapeutic error deaths in older adults. Clin Toxicol (Phila) 2010; 48:68-71. [DOI: 10.3109/15563650903405474] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Starr P, Klein-Schwartz W, Spiller H, Kern P, Ekleberry SE, Kunkel S. Incidence and onset of delayed seizures after overdoses of extended-release bupropion. Am J Emerg Med 2009; 27:911-5. [DOI: 10.1016/j.ajem.2008.07.004] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2008] [Revised: 06/29/2008] [Accepted: 07/02/2008] [Indexed: 11/27/2022] Open
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Doyon S, Klein-Schwartz W. Correspondence. Acad Emerg Med 2009. [DOI: 10.1111/j.1553-2712.2009.00424.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
OBJECTIVES To evaluate the reasons for unintentional therapeutic errors in older adults, the types of medications most frequently involved, and the medical outcomes related to these adverse drug events. DESIGN Retrospective analysis of American Association of Poison Control Center's National Poison Data System (NPDS). SETTING NPDS collects data from all U.S. poison centers. Data from 2002 to 2006 were examined. PARTICIPANTS Cases involving adults aged 65 and older with a potentially toxic exposure due to unintentional therapeutic errors. MEASUREMENTS Hazard factor analysis was conducted to identify medications that pose risk in this population. RESULTS There were 140,786 older adults with reported therapeutic errors, of which 49,320 cases were followed to a known medical outcome. A major effect or death occurred in 596 cases (1.2% of cases with known medical outcome). The most common reasons for therapeutic errors were inadvertently took or given medication twice, wrong medication taken or given, and other incorrect dose. The reasons associated with the highest rate of major effect or death were drug interaction, health professional or iatrogenic error, and more than one product containing same ingredient. Certain medication classes such as analgesics, anticoagulants, anticonvulsants, asthma therapies, psychotherapeutics, and some cardiovascular agents were associated with high hazard factors. CONCLUSION Poison center data can be used to evaluate therapeutic errors in older adults to identify reasons associated with frequently reported errors, as well as reasons and medications involved with errors that result in serious outcomes. Knowing the reasons why they occur can aid in developing strategies for decreasing unintentional errors in older adults.
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Affiliation(s)
- Bryan D Hayes
- Maryland Poison Center, School of Pharmacy, University of Maryland, Baltimore, Maryland 21201, USA.
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Spiller HA, Borys D, Griffith JR, Klein-Schwartz W, Aleguas A, Sollee D, Anderson DA, Sawyer TS. Toxicity from modafinil ingestion. Clin Toxicol (Phila) 2009; 47:153-6. [DOI: 10.1080/15563650802175595] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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