2016 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 34th Annual Report

Predictors for prolonged qt intervals in acute antipsychotic poisoned patients

Background

Acute antipsychotic poisoning is correlated to a high prevalence of qt interval prolongation.

Aim

This study aimed to evaluate early qt interval prolongation predictors in acute antipsychotic-poisoned patients.

Methodology

This prospective cohort study enrolled 70 symptomatic patients with acute antipsychotic poisoning. Sociodemographic data, toxicological, clinical, investigation, and outcomes were collected and analyzed. The estimation of the corrected qt interval (QTc) was performed using Bazett's method. Primary outcome was normal or abnormal length of QTc interval. Secondary outcomes included duration of hospital stay, complete recovery and mortality. The corrected qt interval was analyzed by univariate and multivariate logistic regression analysis.

Results

Patients were divided into groups A (normal QTc interval up to 440 msec; 58.6% of cases) and B (prolonged QTc interval ≥ 440 msec; 41.4% of cases). Patients in group B had significantly high incidences of quetiapine intake, bradycardia, hypotension, hypokalemia, and long duration of hospital stay. By multivariate analysis, quetiapine [Odd's ratio (OR): 39.674; Confidence Interval (C.I:3.426-459.476)], bradycardia [OR: 22.664; C.I (2.534-202.690)], and hypotension [OR: 16.263; (C.I: 2.168-122.009)] were significantly correlated with prolonged QTc interval.

Conclusion

In acute antipsychotic poisoning, quetiapine, bradycardia, and hypotension are early clinical predictors for prolonged QTc interval.

Rhabdomyolysis in the Context of Designer Benzodiazepine Misuse

Designer benzodiazepines belong to a class of lab-created psychoactive compounds, with limited federal regulation, no toxicity testing, and reported high potency, leading to substantial overdose risk and harmful clinical syndromes. Benzodiazepine misuse has been previously documented to be associated with rhabdomyolysis, with elevated creatine kinase (CK) during and after acute episodes of intoxication. Here, we present a case of profound rhabdomyolysis and associated acute kidney injury (AKI) after acute designer benzodiazepine intoxication. A 26-year-old male with a history of poly-substance misuse, including alcohol, psychedelics, opiates, kratom, and benzodiazepines, presented to the emergency department with altered mental status and agitation after an accidental overdose on liquid flubromazolam and clonazolam, designer benzodiazepines purchased online. He went on to develop seizure-like activity. Additional labs revealed AKI with creatinine 2.22 mg/dL (reference 0.74-1.35 mg/dL, baseline 0.88 mg/dL). He was discovered to have severe rhabdomyolysis that peaked at 131,920 U/L (reference 55-170 U/L) on the fourth day of admission. This case demonstrates the potential deleterious effects of the designer benzodiazepine class, including prolonged sedation, AKI, and severe rhabdomyolysis. In addition, seizure-like manifestations may occur during the intoxication or withdrawal phase. Designer benzodiazepines may produce rhabdomyolysis; however, the mechanism is unknown. Direct myotoxicity or prolonged immobilization may be contributors to rhabdomyolysis. More research is needed to elucidate the consequences of designer benzodiazepine misuse. Clinicians should be aware of their use given the ease of availability online and rising popularity.

Evaluation of Physicians' Knowledge About Honey/Sucralfate Treatments in Children With Button Battery Ingestion

OBJECTIVES

Ingestion of button batteries (BBs) causes serious mortality and morbidity. We aimed to evaluate the knowledge level of physicians working in pediatric emergency departments about the updated guidelines for BB ingestion and whether they used honey and sucralfate, which have proven positive effects in preventing mucosal damage, in their daily practice.

METHODS

A "Google Form" questionnaire was prepared and used to evaluate the approach of physicians who worked in pediatric emergency department with questions about pediatric patients who were admitted with the suspicion of BB swallowing.

RESULTS

A total of 263 physicians, 169 women (64.3%), with a mean age of 34.5 ± 7.3 years, participated in the study. Seventy-five percent of the participants were from tertiary care hospitals, and 60.8% had less than 5 years of pediatric emergency experience. Some 71.9% of the physicians who participated in the survey (n = 189) had no algorithm at their hospitals. Fifty-eight percent (n = 152) of the participants completely and correctly answered all our survey questions about battery swallowing. Fifty-eight (22.1%) of the participants administered sucralfate, and 12.2% (n = 32) used honey treatments in patients who swallowed BBs; 68.1% (n = 179) had never heard of the use of sucralfate, and 77.6% (n = 204) had never heard of honey applications before in the management of swallowed batteries.

CONCLUSION

It was determined that the physicians who managed pediatric battery swallowing cases had deficiencies in their treatment approaches, they had no protocol in their institutions, and the use of mucosal damage mitigation and neutralization treatments, such as honey and sucralfate, was insufficient.

Molecular Recognition Mechanism of an Anti-Amatoxins mAb and Its Application in Centrifugal Disk-Based Immunoassay

Amatoxins are polypeptides that cause 90% of fatalities from accidental ingestion of poisonous mushrooms. Unfortunately, there are no specific antidotes against amatoxins poisoning, hence preparation of high-affinity antibodies, understanding the receptor (amatoxins) and ligand (antibody) mechanism, and establishing a straightforward screening approach are of great significance for confirming poison agents and clinical diagnosis. Here, anti-amatoxins monoclonal antibody (mAb) 9B2 was prepared and the recognition mechanism was investigated. The approach is useful for designing desirable immunogens, developing new antibodies with improved performance, and constructing effective immunoassays. Based on the mAb, we designed a centrifugal disk-like microfluidics chip and developed a fully automated immunoassay capable of detecting amatoxins poisoning in various samples including serum, urine, and mushrooms. The whole detection process could be automatically accomplished within 30 min, with a limit of detection of 0.08 to 0.12 μg/L for real samples, ∼30-fold more sensitive than conventional enzyme-linked immunosorbent assay (ELISA). Our platform not only provided a practical approach for performing poison agent confirmation and clinical diagnosis but also had important implications for improving the survival of patients with mushroom poisoning.

Review: Failure of current digoxin monitoring for toxicity: new monitoring recommendations to maintain therapeutic levels for efficacy

The current recommendations for monitoring digoxin, a narrow therapeutic index drug, are limited to confirming medication use or investigating suspicion of toxicity and fail our oath to do no harm. Numerous meta-analyses evaluating digoxin use consistently recommend frequent monitoring to maintain the level of 0.5 to ≤1.0 ng/ml because higher levels lead to increased morbidity and mortality without benefit. Data from the United States National Poison Control Center (2012-2020) show annual deaths due to digoxin of 18-36 compared to lithium's 1-7, and warfarin's 0-2 respectively. The latter drugs also have narrow therapeutic indexes like digoxin yet are more carefully monitored. Recognition of digoxin toxicity is impaired as levels are not being routinely checked after medications are added to a patient's regimen. In addition, providers may be using ranges to guide treatment that are no longer appropriate. It is imperative that monitoring guidelines and laboratory therapeutic levels are revised to reduce morbidity and mortality due to digoxin. In this review, we provide a comprehensive literature review of digoxin monitoring guidelines, digoxin toxicity, and evidence to support revising the ranges for serum digoxin monitoring.

Sex-Based Disparities in Leukocyte Migration and Activation in Response to Inhalation Lung Injury: Role of SDF-1/CXCR4 Signaling

The aim of the study was to determine whether sex-related differences exist in immune response to inhalation lung injury. C57BL/6 mice were exposed to Cl2 gas (500 ppm for 15, 20, or 30 min). Results showed that male mice have higher rates of mortality and lung injury than females. The binding of the chemokine ligand C-X-C motif chemokine 12 (CXCL12), also called stromal-derived-factor-1 (SDF-1), to the C-X-C chemokine receptor type 4 (CXCR4) on lung cells promotes the migration of leukocytes from circulation to lungs. Therefore, the hypothesis was that elevated SDF-1/CXCR4 signaling mediates exaggerated immune response in males. Plasma, blood leukocytes, and lung cells were collected from mice post-Cl2 exposure. Plasma levels of SDF-1 and peripheral levels of CXCR4 in lung cells were higher in male vs. female mice post-Cl2 exposure. Myeloperoxidase (MPO) and elastase activity was significantly increased in leukocytes of male mice exposed to Cl2. Lung cells were then ex vivo treated with SDF-1 (100 ng/mL) in the presence or absence of the CXCR4 inhibitor, AMD3100 (100 nM). SDF-1 significantly increased migration, MPO, and elastase activity in cells obtained from male vs. female mice post-Cl2 exposure. AMD3100 attenuated these effects, suggesting that differential SDF-1/CXCR4 signaling may be responsible for sex-based disparities in the immune response to inhalation lung injury.

A Metabolomics-Based Study on the Discriminative Classification Models and Toxicological Mechanism of Estazolam Fatal Intoxication

Fatal intoxication with sedative-hypnotic drugs is increasing yearly. However, the plasma drug concentration data for fatal intoxication involving these substances are not systematic and even overlap with the intoxication group. Therefore, developing a more precise and trustworthy approach to determining the cause of death is necessary. This study analyzed mice plasma and brainstem samples using the liquid chromatography-high resolution tandem mass spectrometry (LC-HR MS/MS)-based metabolomics method to create discriminative classification models for estazolam fatal intoxication (EFI). The most perturbed metabolic pathway between the EFI and EIND (estazolam intoxication non-death) was examined, Both EIND and EFI groups were administered 500 mg of estazolam per 100 g of body weight. Mice that did not die beyond 8 hours were treated with cervical dislocation and were classified into the EIND groups; the lysine degradation pathway was verified by qPCR (Quantitative Polymerase Chain Reaction), metabolite quantitative and TEM (transmission electron microscopy) analysis. Non-targeted metabolomics analysis with EFI were the experimental group and four hypoxia-related non-drug-related deaths (NDRDs) were the control group. Mass spectrometry data were analyzed with Compound Discoverer (CD) 3.1 software and multivariate statistical analyses were performed using the online software MetaboAnalyst 5.0. After a series of analyses, the results showed the discriminative classification model in plasma was composed of three endogenous metabolites: phenylacetylglycine, creatine and indole-3-lactic acid, and in the brainstem was composed of palmitic acid, creatine, and indole-3-lactic acid. The specificity validation results showed that both classification models distinguished between the other four sedatives-hypnotics, with an area under ROC curve (AUC) of 0.991, and the classification models had an extremely high specificity. When comparing different doses of estazolam, the AUC value of each group was larger than 0.80, and the sensitivity was also high. Moreover, the stability results showed that the AUC value was equal to or very close to 1 in plasma samples stored at 4 °C for 0, 1, 5, 10 and 15 days; the predictive power of the classification model was stable within 15 days. The results of lysine degradation pathway validation revealed that the EFI group had the highest lysine and saccharopine concentrations (mean (ng/mg) = 1.089 and 1.2526, respectively) when compared to the EIND and control group, while the relative expression of SDH (saccharopine dehydrogenase) showed significantly lower in the EFI group (mean = 1.206). Both of these results were statistically significant. Furthermore, TEM analysis showed that the EFI group had the more severely damaged mitochondria. This work gives fresh insights into the toxicological processes of estazolam and a new method for identifying EFI-related causes of mortality.

Multiorgan failure and death from a mixed Dettol and Clorox poisoning: a case report

BACKGROUND

Dettol and sodium hypochlorite have wide use as household disinfectants and cleaners. Intentional and nonintentional ingestion are widespread, mainly causing mild symptoms that require no specific treatment. However, severe complications can occur when large volumes are ingested. Both products affect the same organ systems in the body, which can result in fatalities when ingested together.

CASE PRESENTATION

We present the case of a 26-year-old Asian man who died from multiorgan failure after deliberately ingesting a presumed large volume of Dettol and sodium hypochlorite. The case illustrates the severe complications that can occur with mixed ingestion of these commonly used household products.

CONCLUSION

Clinicians must be aware of the increased risk of death caused by the combined ingestion of chloroxylenol and sodium hypochlorite.

Captive Black Mamba (Dendroaspis Polylepis) Bite Leading to Respiratory Failure

BACKGROUND

Of the 8000-10,000 snake envenomations evaluated in U.S. emergency departments (ED) annually, approximately 1% are due to non-native snakes. We describe a 26-year-old man who was bitten by his captive black mamba (Dendroaspis polylepis) as he was packing it up for transport to another snake collector.

CASE REPORT

The patient presented to the ED 1 h after being bitten on the forearm, complaining of left arm pain, oral paresthesias, and dyspnea. His vital signs: heart rate 96 beats/min, blood pressure 167/101 mm Hg, temperature 36.7°C (97.9°F), respiratory rate 20 breaths/min, and room air oxygen saturation 100%. Two mildly tender puncture wounds without swelling or ecchymosis were found on the posterior aspect of the forearm. Over the ensuing 30 min his dyspnea worsened, and he developed objective weakness. He was intubated and placed on mechanical ventilation. He was treated with atropine 2 mg for bronchorrhea. Five vials of South African Vaccine Producers (Johannesburg, South Africa) polyvalent antivenom were administered 2.5 h post-bite and the patient was admitted to the intensive care unit. He was extubated 18 h post-envenomation and discharged the following day. He has remained asymptomatic since leaving the hospital. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The primary manifestations of D. polylepis envenomings are neurological. Initial signs may include paresthesias, dysarthria, dysphagia, and ptosis. Progressive descending paralysis leading to respiratory failure develops within 60 min. Muscarinic features are frequently observed. Cardiotoxicity and hematologic laboratory abnormalities may be present. Although pain is common, significant local tissue injury does not occur. In addition to supportive care, several non-native antivenoms are indicated for D. polylepis envenomations. Black mamba envenomings differ from the native snakebites with which U.S. physicians are familiar. Rapid, progressive neurological toxicity and muscarinic features are most common. Treatment consists of supportive care and appropriate antivenom administration.

Incidence of Intoxications in the Emergency Department of Galati Hospital with Examples of Cardiovascular Effects of MDMA Intoxication

MDMA (3,4-methylenedioxymethamphetamine; commonly referred to as "Molly" or "ecstasy") is a synthetic compound, structurally and pharmacologically similar to both amphetamines and mescaline. MDMA differs somewhat from traditional amphetamines in that it is not structurally similar to serotonin. Cocaine is rare and cannabis is consumed less frequently than in Western Europe. Heroin is the drug of choice for the poor in Bucharest, Romania's capital of two million people, and alcoholism is common in villages where more than a third of the population lives in poverty. By far, the most popular drugs are Legal Highs (Romanians call them "ethnobotanics"). All of these drugs have significant effects on cardiovascular function that contribute significantly to adverse events. Most adverse cardiac events occur in young adults and are potentially reversible. Poisoning among patients aged 17 years and over was commonly seen in the Emergency Departments of a large tertiary hospital in the city centre, accounting for 3.2% of all patients. In a third of the poisonings, more than one substance was used. Intoxication with ethnobotanicals was the most frequently observed, followed by use of drugs from the amphetamine group. The majority of patients presenting to the Emergency Department were male. Therefore, this study suggests further research on hazardous alcohol consumption and drug abuse.

Analyzing Overlaid Foreign Objects in Chest X-rays-Clinical Significance and Artificial Intelligence Tools

The presence of non-biomedical foreign objects (NBFO), such as coins, buttons and jewelry, and biomedical foreign objects (BFO), such as medical tubes and devices in chest X-rays (CXRs), make accurate interpretation difficult, as they do not indicate known biological abnormalities like excess fluids, tuberculosis (TB) or cysts. Such foreign objects need to be detected, localized, categorized as either NBFO or BFO, and removed from CXR or highlighted in CXR for effective abnormality analysis. Very specifically, NBFOs can adversely impact the process, as typical machine learning algorithms would consider these objects to be biological abnormalities producing false-positive cases. It holds true for BFOs in CXRs. This paper examines detailed discussions on numerous clinical reports in addition to computer-aided detection (CADe) with diagnosis (CADx) tools, where both shallow learning and deep learning algorithms are applied. Our discussion reflects the importance of accurately detecting, isolating, classifying, and either removing or highlighting NBFOs and BFOs in CXRs by taking 29 peer-reviewed research reports and articles into account.

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

BACKGROUND

Anticonvulsants are frequently prescribed, and exposures are commonly reported to American Association of Poison Control Centers sites. The purpose of this study was to describe the epidemiology of fatalities associated with oral anticonvulsant use, including patient demographics, specific medications, and the circumstances surrounding the deaths.

METHODS

This was a retrospective analysis of cases coded with oral anticonvulsants as a single substance and associated with a fatal outcome reported to the AAPCC National Poison Data System from 2000 to 2019. Polydrug ingestions and parenteral exposures were excluded. Patient characteristics, circumstances of the ingestion, specific medication, and chronicity of use were described.

RESULTS

We identified 126 cases that were classified as fatalities associated with single anticonvulsant use. The five most implicated anticonvulsants were carbamazepine, gabapentin, lamotrigine, phenytoin, and valproic acid. The majority (68.3%) of fatal cases were suicides. Phenytoin was implicated in eight (89%) adverse reactions and seven (70%) therapeutic errors. Valproic acid caused one (11.1%) adverse reaction and was associated with one (10%) therapeutic error. Three (75%) unintentional fatalities were caused by carbamazepine. The plurality (42.1%) of fatal ingestions occurred in acute-on-chronic use. An additional 40 (31.7%) were acute. Chronic use accounted for 15 (11.9%) of fatal exposures, including 5/10 of fatalities attributed to therapeutic error. The chronicity of medication use was unknown in 18 (14.3%) of fatal ingestions. Narrative summaries were available in 14 cases. Four of the patients presented to the emergency department with minimal symptoms. The other 10 had varying degrees of central nervous system (CNS) depression. Seizures were observed in six cases. Hyperammonemia was reported in seven of nine valproic acid ingestions.

CONCLUSIONS

Fatalities associated with isolated anticonvulsant use are uncommon and typically occur following intentional overdoses. Fatal adverse reactions and therapeutic errors are most associated with phenytoin use and disproportionately affect elderly patients.

Supraglottic Foreign Body Missed for One Month in a Child

Foreign body (FB) aspiration in children can result in serious complications that can lead to even death. We present a case of a one-year-old girl child with a history of choking one month prior while she was feeding. A bolus of rice was removed at a local clinic. Consequently, within 24 hours, she developed hoarseness and noisy breathing which was treated as an upper respiratory tract infection at two different clinics. This case report aims to highlight the need for otolaryngology consultation in a child with non-resolving respiratory symptoms following episodes of choking. This will prompt an immediate surgical intervention that could prevent potential morbidity and mortality as a result of a compromised airway.

Paracetamol (acetaminophen) overdose and hepatotoxicity: mechanism, treatment, prevention measures, and estimates of burden of disease

INTRODUCTION

Paracetamol is one of the most used medicines worldwide and is the most common important poisoning in high-income countries. In overdose, paracetamol causes dose-dependent hepatotoxicity. Acetylcysteine is an effective antidote, however despite its use hepatotoxicity and many deaths still occur.

AREAS COVERED

This review summarizes paracetamol overdose and toxicity (including mechanisms, risk factors, risk assessment, and treatment). In addition, we summarize the epidemiology of paracetamol overdose worldwide. A literature search on PubMed for poisoning epidemiology and mortality from 1 January 2017 to 26 October 2022 was performed to estimate rates of paracetamol overdose, liver injury, and deaths worldwide.

EXPERT OPINION

Paracetamol is widely available and yet is substantially more toxic than other analgesics available without prescription. Where data were available, we estimate that paracetamol is involved in 6% of poisonings, 56% of severe acute liver injury and acute liver failure, and 7% of drug-induced liver injury. These estimates are limited by lack of available data from many countries, particularly in Asia, South America, and Africa. Harm reduction from paracetamol is possible through better identification of high-risk overdoses, and better treatment regimens. Large overdoses and those involving modified-release paracetamol are high-risk and can be targeted through legislative change.

Two Cases of Severe Amanita Muscaria Poisoning Including a Fatality

Ingestion of Amanita muscaria mushrooms results in transient central nervous system excitation and depression mediated by its components, ibotenic acid and muscimol. The mushroom is distributed worldwide and ingestions occur with some frequency. Although these ingestions have traditionally been considered benign, serious complications can occur. We present 2 cases of serious toxicity, including a fatality. The first case was a 44-y-old man who presented to the emergency department (ED) after cardiopulmonary arrest approximately 10 h after ingesting 4 to 5 dried A muscaria mushroom caps, which he used for their mind-altering effects. Despite successful resuscitation, he remained unresponsive and hypotensive and died 9 days later. The second case was a 75-y-old man who presented to the ED after accidentally consuming one large A muscaria mushroom cap he foraged in Eastern Turkey. The patient initially presented to the ED with hallucinations followed by lethargy, and he was intubated for airway protection. The patient's condition gradually improved, and he made a full recovery. A muscaria ingestion should not be considered benign as serious outcomes do occur. An understanding of how the main neuroactive chemicals, ibotenic acid and muscimol, affect the brain can help anticipate outcomes. Several high-risk features that portend a more serious course are identified.

A Study on the Profile of Poisoning in the Paediatric Population in a Tertiary Care Teaching Hospital of Chitradurga Region

Background Most poisoning events among children are preventable and the major reason is lack of supervision by adults, including poor knowledge and attitude toward storage of such items. So, the prevention policy on children's poisoning shall take into account the age group, gender, socioeconomic status, residence, and other aspects such as the knowledge and attitude of adults. The present study was conducted to describe the profile of poisoning in the paediatric population in a tertiary care teaching hospital. Methods Our observational study was retrospective and was conducted at Basaveshwara Medical College and Hospital (BMCH), Chitradurga, Karnataka, under the Department of Forensic Medicine for a duration of three months (February 2021 to April 2021). Institutional ethical approval was obtained prior to the start of the study. As our study participants were paediatric patients (0-17 years) with acute poisoning (excluding homeopathic drug ingestion), a total of 81 paediatric patients' case sheets were finally reviewed and analysed. The data of paediatric poisoning cases were collected in a predesigned study proforma and included details about children's age (in years), gender (male, female), residence (rural, urban), outcome (death, discharge), nature of poisoning (accidental, suicidal), and toxic agents in poisoning. The collected data were entered and analysed in the Microsoft Excel spreadsheet (Microsoft Corporation, Redmond, WA). Results The incidence of acute poisoning among the paediatric population in our teaching hospital was 1.4%. The most common age group with acute poisoning was 13-17 years (30.9%). The prevalence of acute poisoning was higher in male children (56.8%) when compared to female children (43.2%). Around three-fourths of paediatric cases (71.6%) with acute poisoning were having a rural residence. The overall mortality rate among children due to acute poisoning was 9.9%. The most common toxic agents involved in acute poisoning among children were organophosphate compounds (35.8%), followed by organochlorine compounds (30.9%) and pyrethrum compounds (11.1%). Conclusion From this study, we concluded that acute poisoning among children is mainly accidental, and the most common toxic agent responsible for the poisoning is pesticide or insecticide. Most poisoning events among children are preventable, and the major reason is a lack of supervision by adults, including poor knowledge and attitude toward storage of such items.

Analysis of ingestion admissions in a midsized pediatric intensive care unit

BACKGROUND

Pediatric ingestion of toxic substances is a complicated cause of morbidity. Currently, there is limited literature on toxic ingestions resulting in pediatric intensive care unit (PICU) admissions.

METHODS

A retrospective study was conducted to quantify the number and financial costs of admissions for toxic ingestion. Secondary objectives were to determine common types of ingestions and interventions as well as examine the relationship between intentional ingestion status and patient age. Data were obtained from a retrospective review of records from April 2016 through August 2018 from a PICU located in the Midwestern USA.

RESULTS

There were 360 unique patient encounters used in primary analyses. Intentional ingestion and suicidal ideation documented in 72% and 54% of patients, respectively.Patients younger than nine had an 87% (95% confidence interval: 80%, 92%) lower risk for intentional ingestion. The median lengths of stay were 1.0 (interquartile range [IQR]: 1.0, 1.0) days with a median cost of $2498 (IQR: $1870, $3592) USD. There was no patient mortality identified in the sample.

CONCLUSION

The types of ingestions appeared to match those of the National Poison Control Database. Lengths of stay were short and had a non-nominal cost. A greater age was associated with an increased risk of intentional ingestions.

Acute poisoning in children: Etiology, structure, treatment tactics and outcomes

Introduction: Acute poisoning is often observed in children and can have serious consequences since it is characterized by rapid development of symptoms and obvious disfunction of vital organs.

Materials and methods: Retrospective analysis of the case histories of the children with acute poisoning admitted to Voronezh Regional Children’s Clinical Hospital No. 1 in 2016–2019 was carried out. Anamnesis, clinical and laboratory studies and effective treatment criteria were entered into electronic spreadsheets and served as the basis for a database on children’s poisoning.

Results and discussion: Analysis of 183 case histories of children with intoxication aged 4 months to 17 years old was performed. Distribution per age showed bimodal peaks at 1–2 years and 13–14 years. Poisoning was accidental in 96.2% of the cases, and 3.8% of the adolescents reported suicide cases. In the group of young children, acute drug poisoning is more frequent in girls (P < 0.05). In the older groups, there is no gender difference in frequency of poisoning cases.

Early call for medical help is typical for the adolescent age group. Correlation between time of help-seeking and children’s age is statistically significant (correlation coefficient r = 0.38, P < 0.05).

Conclusion: Study of poisoning issue in children will allow to carry out targeted preventive measures to reduce the number of poisoning cases, prevent their consequences and to determine the most rational modus operandi for medical personnel for effective and safe pharmacotherapy.

Graphical abstract

In pediatric practice, intoxication by poisons and drugs is among the most common reasons for seeking medical help and hospitalization in intensive care units. It is important to study and record dynamics, structure and frequency of acute poisoning with subsequent development of prevention and treatment methods.

Safety of chronic high-dose calcium channel blockers exposure in children with pulmonary arterial hypertension

Background

Chronic calcium channel blockers (CCBs) are indicated in children with idiopathic/heritable pulmonary arterial hypertension (IPAH/HPAH) and positive response to acute vasodilator challenge. However, minimal safety data are available on the long-term high-dose exposure to CCBs in this population.

Methods

Patients aged 3 months to 18 years who were diagnosed with IPAH/HPAH and treated with CCB in the past 15 years were retrospectively reviewed. The maximum tolerated dose and the long-term safety of high-dose CCBs on the cardiovascular and noncardiovascular systems were assessed.

Results

Thirty-two eligible children were enrolled in the study, with a median age of 9 (6–11) years old. Thirty-one patients were treated with diltiazem after diagnosis. The median maximum tolerated dose was 12.9 (9.8–16.8) mg/kg/day. Children younger than 7 years used higher doses than children in the older age group, 16.4 (10.5–28.5) mg/kg/day vs. 12.7 (6.6–14.4) mg/kg/day, P < 0.05. Patients were followed up for a median period of 6.2 (2.6–10.8) years. One patient died from a traffic accident, and others showed a stable or improved WHO functional class status. Thirteen (40.6%) and 10 (31.3%) patients developed arrhythmias and hypotension. Nine (28.1%) patients had sinus bradycardia, five (21.9%) had first-degree or second-degree type II atrial-ventricular blocks, and two (6.3%) had second-degree type II atrial-ventricular blocks. Most of these arrhythmias were transient and relieved after CCB dose adjustment. The most reported noncardiovascular adverse effect was gingival hyperplasia (13, 40.6%), accompanied by different degrees of dental dysplasia. No liver or kidney dysfunction was reported.

Conclusion

Diltiazem was used in a very high dose for eligible children with IPAH/HPAH. The toxicity of long-term CCB use on the cardiovascular system is mild and controllable. Clinicians should also monitor the noncardiovascular adverse effects associated with drug therapy.

Delayed Recognition of Severe Systemic Envenomation after Copperhead Bite: A Case Report

Introduction

We report a case of severe systemic copperhead, Agkistrodon contortrix, envenomation that resulted in long-term sequelae.

Case Report

A 72-year-old man presented to the emergency department after suffering a copperhead snakebite. He developed severe systemic toxicity before local tissue injury developed. Clinicians did not initially recognize his envenomation syndrome and sought alternative explanations for his systemic symptoms before polyvalent immune fab (ovine) antivenom was administered. Although the patient improved, he was discharged with new stage three chronic kidney disease.

Conclusion

Although rare, copperhead envenomation can cause severe systemic toxicity. Envenomation should be promptly treated with antivenom.

Important Advances in Pediatric Injury Prevention

In children, injuries are the leading cause of death, a major source of disability, and the number one cause of death for children after the first year of life. The principles of injury prevention include surveillance, coalitions, communication, interventions, and evaluation. This article discusses a number of common pediatric injuries and their prevention strategies. This review article addresses key components of injury prevention and specifically addresses the following injuries: motor vehicle crashes (with a section on teen driver crashes, sleep-related injury, and death), poisoning, all-terrain vehicle crashes, drowning, and firearm injuries. Injuries are preventable occurrences that can result in devastating sequelae or death. We present an overview of the more common pediatric injuries along with injury-prevention strategies.

Advances and horizons for artificial intelligence of endoscopic screening and surveillance of gastric and esophageal disease

The development of artificial intelligence in endoscopic assessment of the gastrointestinal tract has shown progressive enhancement in diagnostic acuity. This review discusses the expanding applications for gastric and esophageal diseases. The gastric section covers the utility of AI in detecting and characterizing gastric polyps and further explores prevention, detection, and classification of gastric cancer. The esophageal discussion highlights applications for use in screening and surveillance in Barrett's esophagus and in high-risk conditions for esophageal squamous cell carcinoma. Additionally, these discussions highlight applications for use in assessing eosinophilic esophagitis and future potential in assessing esophageal microbiome changes.

Consumer knowledge and awareness of the toxicity and handling of household products at a tertiary care center in Beirut, Lebanon

Household products intoxication is a common and preventable problem. Household product hazard awareness is lacking among consumers in Lebanon, posing a public health hazard. A cross-sectional observational study was conducted at the American University of Beirut Medical Center by administering surveys to 176 adult participants. The surveys focused on demographics, awareness of product toxicity, practices used to avoid intoxication, and sources of information. Each participant was given a score for behavior and awareness. Informative brochures were handed to increase awareness among consumers. We surveyed 176 patients, of whom (84.7%) were females with a mean age of 42.2 ± 13.5 years. Most were married (77.3%), had a college education (76.7%), were employed (62.5%), and were in charge of household cleaning (76.7%). Toilet cleaners were the substances most perceived to be toxic (94.0%). Most people (86.4%) had low to medium scores on behavior, while most (77.3%) had high scores on awareness. Male gender and using product labels as sources of information were associated with higher behavior scores, while referring to a friend or a relative as a source of information on product intoxication was associated with a lower behavior score. Greater awareness scores were strongly associated with being married, having a higher monthly income, and referring to warning signs presented on the labels as a source of knowledge. Unsafe handling and storage of household products are common among consumers in our population. Therefore, it may be necessary to launch education campaigns to improve consumer handling of household products.

Seniors and single-use detergent sacs (SUDS): a review of the National Poison Data System from 2012 to 2020

INTRODUCTION

Exposure to single-use detergent sacs (SUDS), or laundry pods, have declined in the pediatric population between 2015 and 2018. Older adult exposures are less well described, and it is unclear if there is an increased risk of unintentional exposure to SUDS in older adults, especially in those with dementia. This study aims to review SUDS exposures in adults greater than 60-year-old between 2012 and 2020.

METHODS

Using the National Poison Data System (NPDS), a query was performed for cases involving an acute single substance exposure with substance coded as "laundry detergent unit dose" (Generic code: 0201181, 0201182, and 0201183) in adults greater than 60-years-old between January 1, 2012 and December 31, 2020. Exclusion criteria included unknown age, age less than 60 years, any multi-substance exposure, and chronic or acute-on-chronic acuity. The distribution of cases was analyzed for demographics, exposure circumstances, management, clinical effects, and medical outcome.

RESULTS

SUDS exposure reported to NPDS increased from 46 cases in 2012 to 219 cases in 2020. Among the 1289 total reported cases, 94.9% (n = 1223) were unintentional exposures with an average age of 75-year-old. The majority of exposures occurred in females (69%, n = 883). More than 1 exposure route was reported in 90 cases (7%), and the most common route of exposure was ingestion (64.9%, n = 836). Major effects were identified in 1% (n = 13) of exposures, and 0.5% (n = 7) of cases resulted in death.

CONCLUSIONS

Despite a declining incidence of pediatric SUDS exposure, older adult exposures have increased over 400% between 2012 and 2020.

Recent advances in nanoremediation: Carving sustainable solution to clean-up polluted agriculture soils

Agriculture is one of the foremost significant human activities, which symbolizes the key source for food, fuel and fibers. This activity results in a lot of ecological harms particularly with the excessive usage of chemical fertilizers and pesticides. Different agricultural practices have remained industrialized to advance food production, due to the growth in the world population and to meet the food demand through the routine use of more effective fertilizers and pesticides. Soil is intensely embellished by environmental contamination and it can be stated as "universal incline." Soil pollution usually occurs from sewage wastes, accidental discharges or as byproducts of chemical residues of unrestrained production of numerous materials. Soil pollution with hazardous materials alters the physical, chemical, and biological properties, causing undesirable changes in soil fertility and ecosystem. Engineered nanomaterials offer various solutions for remediation of contaminated soils. Engineered nanomaterial-enable technologies are able to prevent the uncontrolled release of harmful materials into the environment along with capabilities to combat soil and groundwater borne pollutants. Currently, nanobiotechnology signifies a hopeful attitude to advance agronomic production and remediate polluted soils. Studies have outlined the way of nanomaterial applications to restore the eminence of the environment and assist the detection of polluted sites, along with potential remedies. This review focuses on the latest developments in agricultural nanobiotechnology and the tools developed to combat soil or land and or terrestrial pollution, as well as the benefits of using these tools to increase soil fertility and reduce potential toxicity.

Evaluation of accidental and intentional pediatric poisoning: Retrospective analysis in an emergency Department of Turkey

INTRODUCTION

Childhood poisoning is one of the leading causes of applications to ED and is a preventable cause of morbidity and mortality. The characteristics of poisoning may differ by geographic region, season, and the sociocultural aspects of the community and age groups.

METHOD

Poisoned patients age ≤ 18 years admitted to the ED January 2018-December 2019, were evaluated retrospectively.

RESULTS

Of 170 cases, mean age was 7.48 ± 5.54 years. Of the cases, 0-5 years (44.1%), 6-12 years (24.7%), and 13-18 years (31.2%); most were female (58.2%). Causes were accidental (72.9%), intentional (24.1%), and substance use (2.9%). Accidental cases were all patients age 0-5 years, 31.8% of age 6-12 years, and 24.5% of age 13-18 years. Drugs caused 72.9% of cases, primarily analgesics (22.4%), among which nonsteroidal anti-inflammatory drugs were most common (12.4%). Intentional poisoning by repeated drug intake caused 5.9% of cases. Rat poison caused 7.1% of non-drug cases. Treatment was gastric lavage (52.4%) and oral activated charcoal (45.9%).

CONCLUSION

As a result of the study, it was determined that accidental drug intake was the most common reason for children to apply to the ED due to acute poisoning in our region. Childhood poisoning can be prevented by measures to be taken by the environment, family, and healthcare professionals.

PRACTICE IMPLICATIONS

The fact that children's acute poisoning cases are mostly accidental in our region shows that it is important to raise the awareness of parents to reduce acute poisoning and alleviate its negative consequences.

Characterization of aerosols produced during shampoo use and harmful chemicals in shampoo aerosols

To declare a shampoo toxicologically safe, one should evaluate the hazards posed by the inhalation of aerosols produced during its use. Herein, tap water was sprayed into a shampoo-filled plastic container to investigate the formation of shampoo aerosols and the possibility of their inhalation. The aerosols thus obtained had higher mass concentrations (geometric mean = 5779 μg m^-3 (PM₁₀) and 2249 μg m^-3 (PM_2.5)) than water aerosols (geometric mean = 927 μg m^-3 (PM₁₀) and 476 μg m^-3 (PM_2.5)). In particular, shampoo aerosol particles with an aerodynamic diameter of 2.5 μm, which can penetrate the alveoli when inhaled, had the highest mass concentration (geometric mean = 2000 μg m^-3). The volatile organic compounds contained in shampoo aerosols featured alcohol and ether groups attached to dodecane and tetradecane backbones; these compounds were generated by the thermal decomposition of surfactants (i.e., lauryl and laureth sulfates) during instrumental analysis. The acquired data suggest that inhalation exposure and chronic inhalation toxicity evaluations should be performed for various shampoo usage conditions to ensure inhalation safety.

Trends and characteristics of ocular exposures related to e-cigarettes and e-liquids reported to Poison Control Centers in the United States, 2010-2019

INTRODUCTION

Ocular injuries and unintended exposures involving electronic nicotine delivery systems (ENDS), also known as e-cigarettes, have been reported. However, trends and characteristics of ENDS-related ocular exposures at the population level are not well documented. This study was designed to describe trends and characteristics of ENDS-related ocular exposure cases reported to poison control centers (PCCs) in the U.S.

METHODS

We computed descriptive statistics of ENDS-related ocular exposure cases reported to PCCs between January 1, 2010 and December 31, 2019, including number of cases per year and the distribution of characteristics of those cases. We also summarized case narrative review findings.

RESULTS

A total of 1,393 ENDS-related ocular exposure cases were reported to PCCs during the study period. Overall number of cases increased from two in 2010 to a peak of 389 in 2014, followed by a steady decline in 2015-2018. Of the 1,393 cases, 42.5% occurred among individuals aged 25 years and older; 20.4 and 17.7% occurred among young adults aged 18-24 years and children younger than five years, respectively. Nearly one quarter (23.8%) of the individuals experiencing ocular exposure sought or were recommended to seek medical attention. Case narrative review found that 59 of 127 (46.5%) cases were due, at least in part, to incorrect use or handling of the products.

DISCUSSION AND CONCLUSIONS

Our study shows that more than 1,000 ENDS-related ocular exposure cases were reported to PCCs during the study period. Many of these cases involved young children; nearly half were due, at least in part, to incorrect use or handling of the products. Future efforts to prevent these exposures may focus on improving the awareness of the potential harmful effects of ENDS products and the importance of appropriate handling of ENDS products. Health care professionals may play an important role in educating patients and improving surveillance of ENDS-related ocular exposure cases.

Fallberichte: Kinder mit tracheoösophagealer Fistel nach Knopfbatterieningestion

Fremdkörperingestionen bei Kindern nehmen stetig zu – dabei werden u. a. Knopfbatterien sehr häufig verschluckt. Das weitverbreitete Modell CR2032 führt bereits nach kurzer Zeit zu schweren Laugenverätzungen mit möglicher Perforation in benachbarte Organe. Dieser Fallserienbericht stellt 4 Kinder vor, die nach Ingestion von Knopfbatterien eine tracheoösophageale Fistel entwickelten und in unserer Kinderklinik interdisziplinär versorgt wurden.

Efficacy of lipid emulsion therapy in treating cardiotoxicity from diphenhydramine ingestion: a review and analysis of case reports

INTRODUCTION

Lipid emulsion therapy (LET) has been most thoroughly studied to reverse local anesthetic systemic toxicity (LAST). Case reports suggest that LET can successfully rescue cardiovascular collapse from bupropion, amitriptyline, and propranolol. The efficacy of LET against refractory hypotension and dysrhythmias from diphenhydramine, a commonly ingested lipophilic cardiotoxic agent, is less well described.

OBJECTIVE

Summarize the evidence that LET rescues cardiac ion channel blockade (QRS, QTc widening) or hypotension attributable to diphenhydramine overdose.

METHODS

We searched MEDLINE, EMBASE, and Google Scholar for English-language full-length case reports of diphenhydramine (DPH) intoxication in patients 17 years of age or older. We extracted data with a PRISMA-compliant protocol, dividing the case reports into two groups, one that received LET and one that did not. We performed a pooled analysis to compare the change in mean arterial pressure (MAP), QRS duration, and QTc duration between the two groups.

RESULTS

We identified 23 reports (25 patients). Lipid emulsion therapy (LET) was used in 6 cases because the patient suffered from hypotension refractory to traditional resuscitation. Those who received LET and those who did not were comparable in age, gender, amount ingested, and frequency of seizures. The mean arterial pressure (MAP) decreased by 4.5 ± 11.5 mm Hg in those who did not receive LET compared to an increase in MAP 37 ± 17.5 mm Hg in those who did receive LET. The QRS narrowed by 29 ± 33.9 ms (no LET group) vs 68 ± 49.5 ms (LET group) and QTc by 168.5 ± 126.75 ms (no LET group) vs 134 ± 88 ms (LET group). All values are expressed as median ± interquartile range. One out of the 6 patients who received LET died after withdrawal of care. In the group that did not receive LET 4 out of 19 died and 3 had no outcome reported.

DISCUSSION

LET may improve MAP in patients with hypotension refractory to vasopressors due to diphenhydramine toxicity. We found no significant effect of LET on QRS or QTc duration. These results are limited by a small sample size, reporting bias of case reports, incomplete data, and heterogeneity.

CONCLUSION

An analysis of pooled case reports suggests that LET may rescue hypotension when other methods have failed in patients with hypotension attributable to diphenhydramine overdose.

Medication Use and Storage, and Their Potential Risks in US Households

Background: Medications stored in US households may pose risks to vulnerable populations and the environment, potentially increasing societal costs. Research regarding these aspects is scant, and interventions like medication reuse may alleviate negative consequences. The purpose of this study was to describe medications stored in US households, gauge their potential risk to minors (under 18 years of age), pets, and the environment, and estimate potential costs of unused medications. Methods: A survey of 220 US Qualtrics panel members was completed regarding medications stored at home. Published literature guided data coding for risks to minors, pets, and the environment and for estimating potential costs of unused medications. Results: Of the 192 households who provided usable and complete data, 154 (80%) reported storing a medication at home. Most medications were taken daily for chronic diseases. The majority of households with residents or guests who are minors and those with pets reported storing medications with a high risk of poisoning in easily accessible areas such as counters. Regarding risk to the aquatic environment, 46% of the medications had published data regarding this risk. For those with published data, 42% presented a level of significant risk to the aquatic environment. Unused medications stored at home had an estimated potential cost of $98 million at a national level. Implications/Conclusions: Medications stored at home may pose risks to vulnerable populations and the environment. More research regarding medications stored in households and their risks is required to develop innovative interventions such as medication reuse to prevent any potential harm.

Antemortem and postmortem rodenticide analysis in forensic toxicology as a part of an LC-MS/MS-based multi-target screening strategy

Since rodenticides represent a substance group relevant in toxicological analyses, the aim of this work was the development of a complex multi-target screening strategy for the identification with liquid chromatography-tandem mass spectrometry. A simple protein precipitation was used as the sample preparation strategy. Further, a Luna 5 μm C18 (2) 100 Å, 150 × 2 mm analytical column was applied for the separation of relevant analytes with a Shimadzu HPLC. Signal detection was performed with a SCIEX API 5500 QTrap MS/MS system. The rodenticides investigated (α-chloralose, brodifacoum, bromadiolone, coumatetralyl, difenacoum, and warfarin) could be incorporated effectively into a multi-target screening strategy covering about 250 substances representing different groups with a limit of detection appropriate for substance identification. The strategy can easily be modified to perform semi-quantitative measurements for this substance group and could be supplemented by quantification based on standard addition.

Single-Pass Albumin Dialysis as Rescue Therapy for Pediatric Calcium Channel Blocker Overdose

Calcium channel blocker ingestions remain one of the leading causes of death related to cardiovascular medication ingestion in both adults and pediatric patients. We report a case of a 17-year-old, 103 kg female presenting after an intentional polypharmacy ingestion, including 500 to 550 mg of amlodipine. She presented with profound vasoplegia and cardiovascular collapse requiring high-dose inotropes and eventual life support with extracorporeal membrane oxygenation (ECMO). Current available treatments, designed for adults, including lipid emulsion and methylene blue, provided no sustained clinical improvement. This resulted in the initiation of single-pass albumin dialysis (SPAD). We aim to describe the clinical implications, amlodipine toxic dose effects, and clinical challenges associated with large pediatric patients and high-dose medications. We also discuss several challenges encountered related to dosing and concentration of medications, which led to fluid overload. Given the ongoing obesity epidemic, we routinely see pediatric patients of adult size. This will continue to challenge pediatric use of adult dosing and concentrations to avoid excessive fluid administration for high-dose medications, such as insulin and vasoactive agents. To our knowledge, this is the first successful case of using SPAD in conjunction with ECMO for salvage therapy after refractory life-threatening calcium channel blocker toxicity.

Managing Pediatric Foreign Body Ingestions: A 10-Year Experience

BACKGROUND

Foreign body (FB) ingestion is a common global issue in pediatrics. Most of the ingested FBs pass through the gastrointestinal tract, but up to 20% of cases require endoscopic removal. In this study, we retrospectively reviewed all pediatric cases of FB ingestion requiring endoscopic removal over a 10-year period in a tertiary hospital to compare the symptoms at presentation and outcomes with those reported in previous studies and to assess the association of the outcomes with patient and FB characteristics.

METHODS

A retrospective chart review of children 16 years or younger who underwent upper endoscopy for FB ingestion from 2008 to 2018 in a tertiary hospital was included. Data on demographics, clinical presentation, characteristics of FBs, endoscopic findings, and outcomes were reviewed. The clinical data were further evaluated to determine the circumstances surrounding FB ingestion, FB management, and patient outcomes. Descriptive analysis of the data was performed using medians, frequencies, and percentage; χ2 or Fisher exact test was used to assess the dependence between categorical variables.

RESULTS

Eighty-six patients (median age, 5.1 years; 67% males) underwent endoscopy for suspected FB ingestion, with a confirmation rate of 91%. Coins were the most commonly ingested FBs (n = 49, 57%). Most patients were symptomatic (84%); 97% of patients in whom the FB had an esophageal location and all patients in whom the FB was not detected by endoscopy were symptomatic (P = 0.007). The most frequent symptoms were drooling (70%) and unexplained crying (48%). Unexplained crying was more common in younger than in older patients (P < 0.001). The FB was more likely to be located in the esophagus in patients with drooling (P < 0.001) and dysphagia (P < 0.001). The distribution of FB location differed according to the FB type, with coins most frequently located in the esophagus and sharp and other FBs in the stomach (P = 0.023). Only 7 patients (8%) developed mild FB-related mucosal injury. No complications occurred during FB removal. All patients had an uneventful outcome.

CONCLUSIONS

Foreign body ingestion is common among younger children, and the clinical presentation can be variable. The presence or absence of symptoms, as well as the type of symptom, could aid clinicians in implementing diagnosis and proper management approaches in patients who ingest FBs requiring endoscopy.

Pediatric Lamp Oil Injuries Treated in US Emergency Departments

OBJECTIVE

Ingestion and aspiration of lamp oil may result in serious adverse effects and even death. The objective of this study was to describe pediatric lamp oil-related injuries treated at US emergency departments (EDs).

METHODS

Cases were lamp oil-related injuries among patients aged 0 to 5 years reported to the National Electronic Injury Surveillance System during 2001-2018. The distribution of the number of cases and national estimate were determined for selected variables.

RESULTS

A total of 317 pediatric lamp oil-related injuries treated at US EDs during 2001-2018 were identified, resulting in a national estimate of 9501 injuries (95% confidence interval, 6937-12,065). The national estimate declined from 1599 in 2001 to 59 in 2014 before increasing once more to 596 in 2017. The patients were 5.4% aged less than 1 year; 62.2%, 1 year; 23.0%, 2 years; 6.6%, 3 years; 2.2%, 4 years; and 0.6%, 5 years; 68.6% of the patients were boys and 31.4% were girls. Ingestions accounted for 91.9% of the injuries, and 82.1% occurred at home. The disposition of the patient was treated or examined and released (68.2%), treated and transferred to another hospital (13.2%), treated and admitted for hospitalization (14.4%), held for observation (4.2%), and not recorded (0.1%).

CONCLUSIONS

Although the estimated number of lamp oil-related injuries declined during 2000-2014, it increased during 2015-2017. Most of the patients were aged 1 to 2 years and boys. The majority of the injuries occurred by ingestion and at home. Most of the patients were treated or evaluated and released from the ED.

Case study: Cinnamon aspiration in a toddler causing severe ARDS requiring surfactant and extracorporeal membrane oxygenation

As many as 6% of reported cinnamon poisonings cause significant clinical effects, however, descriptions of pulmonary toxicity have not yet been reported. Here, we present a pediatric patient's hospital course following powdered cinnamon aspiration. The early presentation with hypercapnia and lower airways obstruction evolved to hypoxemic respiratory failure and severe pediatric acute respiratory distress syndrome requiring a 7-day course of veno-venous extracorporeal membrane oxygenation, 16 ventilator-days, and three diagnostic and therapeutic bronchoscopies with two applications of surfactant therapy. The sum of these modalities contributed to this patient's survival and subsequent return to respiratory baseline 6 months post-hospitalization.

Prolonged use of paracetamol and the prescribing patterns on rehabilitation facilities

AIMS AND OBJECTIVES

The study investigated: (a) the usage patterns of paracetamol, and (b) the association between paracetamol use and patient outcomes such as liver and kidney functions among older people.

BACKGROUND

Paracetamol is a well-known analgesic and antipyretic drug, with an excellent safety profile when used within its recommended dose. It is a commonly used drug by people aged over 65 years to treat chronic pain. Prolonged use of paracetamol in the elderly is poorly understood. As such, there is a genuine risk among older people of unintentional overdose.

METHODS

A retrospective analysis of medical records in rehabilitation wards was undertaken from 1 July 2016 to 30 June 2017. Patients' paracetamol use, prescribing patterns and biochemical results were analysed to assess for differences in admission and discharge biochemistry results. The TREND Statement was utilised to guide study reporting (Enhancing the QUAlity and Transparency Of health Research, 2021).

RESULTS

A total of 1119 patients were admitted for seven or more days in a metropolitan tertiary hospital in Melbourne. Almost three-quarters (74%) of patients were administered paracetamol; 76.1% received Immediate-Release Paracetamol (IRP), and 23.9% were given Sustained-release paracetamol (SRP). A proportion (4.5%) of patients in both the IRP and SRP groups received more than the daily recommended dose. There were limited statistically significant differences between patients' admission and discharge biochemistry results; group or time differences were observed, which were indicative of improvements within the paracetamol group.

CONCLUSION

Paracetamol was a commonly used medication among long-stay elderly patients. Precaution to ensure paracetamol use does not exceed recommended daily doses is required. This study suggests that paracetamol used at a therapeutic level in older patients had limited, negative associations with liver and kidney function.

RELEVANCE TO CLINICAL PRACTICE

The clinical practice regarding prolonged use of paracetamol is ambitious. The increased risk of paracetamol toxicity among the frail elderly is a concern. Optimising the dose adjustment in the elderly is important to avoid adverse outcomes.

Pediatric Exposures Reported to the Toxicology Investigators Consortium, 2010-2015

BACKGROUND AND OBJECTIVE

Poisoning is the leading cause of injury death in pediatric patients. Hospital and provider readiness, including pharmacy stocking, depends on reliable surveillance data describing local patterns of age-specific clinically significant exposures and the therapeutic modalities employed in their treatment. We aimed to characterize trends in clinically significant toxic exposures and their management.

METHODS

We performed a retrospective review of patients 18 years or younger in the American College of Medical Toxicology's Toxicology Investigators Consortium (ToxIC) Registry, a self-reporting database completed by bedside consulting medical toxicologists. We reviewed cases from January 1, 2010, through December 31, 2015. In 2015, ToxIC included 101 health care facilities. Data collected included demographics, geographic region, encounter and exposure details, survival, and therapeutic modalities employed, including antidotes, antivenoms, gastric decontamination, enhanced elimination, hyperbaric oxygen therapy, and extracorporeal membrane oxygenation.

RESULTS

From 2010 to 2015, 11,616 consults were recorded in ToxIC. Pediatric consultations increased from 934 (23.7%) in 2010 to 2425 (29.9%) in 2015 (P < 0.001). Exposures were most commonly reported in females (57.8%) and adolescents (59.4%). Intentional ingestions (55.5%) comprised the majority of cases. The most frequent agents of exposure were analgesics (21.0%). There were 38 deaths reported (0.9%). The antidote used most commonly was N-acetylcysteine (11.0%). Geographic variation was demonstrated in prevalence of envenomations and heavy metal exposures, their respective treatments, and overall use of decontamination.

CONCLUSIONS

Toxicology consultations for pediatric exposures increased from 2010 to 2015. Understanding which pediatric exposures require toxicologist management, the therapies most frequently employed, and geographical patterns is paramount to facility-level planning, pharmacy stocking, and provider education.

Unintentional Pediatric Poisoning Exposures in an Emergency Department: A Comparison of Poison Control Center Referrals and Caregiver Self-Referred Visits

OBJECTIVES

The purpose of this study is to describe the demographics and clinical characteristics of patients referred to a pediatric emergency department (ED) for unintentional poisoning exposures by a poison control center (PCC) compared with patients/caregivers who self-refer.

METHODS

The electronic data warehouse at a pediatric hospital was queried from October 1, 2014, to September 30, 2015, for unintentional poisoning-related ED visits and subsequent inpatient admissions. Eligible patients aged 18 years and younger were identified by International Classification of Diseases, Ninth Revision, Clinical Modification codes for pharmaceuticals, non-pharmaceuticalchemicals, fumes/vapors, foreign bodies, adverse food reactions, food poisoning, and bites/stings. Referral classification (PCC referral vs self-refer) was determined by PCC and hospital medical records.Descriptive statistics were used to characterize the patient demographics and ED visits by referral classification and age group. Simple and multiple logistic regression models examined the individual and combined impact of demographic and clinical characteristics on self-referral.

RESULTS

Of the 705 patients identified, 84.4% presented as caregiver/self-referred compared with PCC-referred. As compared with those who self-referred, a higher percentage of patients who contacted the PCC before ED presentation were white (93.9% [89.4-98.2%] vs 83.8% [80.7-86.7%]) and had commercial insurance (62.7% [51.5-69.5%] vs 53.0% [48.9-57.0%]). Pharmaceutical (71.9%) and chemical (14.0%) exposures were the most common exposure types for PCC-referred patients whereas foreign bodies (54.3%) were the most common for self-referred patients. The largest predictors of self-referral were age, insurance, and exposure type.

CONCLUSIONS

Among patients presenting at 1 pediatric ED, disparities with PCC utilization exist among age groups, racial identification, and poison exposure type. Educational outreach interventions are needed to ensure optimal use of the PCC services by patients, caregivers, and health care professionals.

Enterosorption in the Treatment of Heavy Metal Poisoning

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

Profile of referrals to an intensive care unit from a regional hospital emergency centre in KwaZulu-Natal

Introduction

The objective was to describe the clinical characteristics, disease profile and outcome of patients referred from a regional hospital Emergency Centre (EC) to the Intensive Care Unit (ICU).

Methods

A retrospective review was performed using data extracted from the Integrated Critical Care Electronic Database (iCED). Data were extracted from the database with respect to patient characteristics, Society of Critical Care Medicine (SCCM) grading, and outcome of the ICU referral. Modified early warning scores (MEWS) were calculated from EC referral data.

Results

There were a total of 2187 referrals. Of these, 56.3% (1231/2187) were male. The mean age of referrals was 36 years. Of the referred patients, 41.5% (907/2187) were initially accepted for admission. A further 378 patients were accepted for admission after a follow up ICU review. Medical conditions accounted for the majority of patient referrals, followed by general surgery and trauma. Most patients initially accepted to ICU were classified as SCCM I and II and had a mean MEWS of 4. Almost half of the patients experienced a delay in admission, most commonly due to a lack of ICU bed availability. ICU mortality was 13.6% for patients admitted from the EC.

Discussion

The EC population referred to the ICU was young with a high burden of medical and trauma conditions. Decisions to accept patients to ICU are limited by available resources, and there was a need to apply ICU triage criteria. Delays in the transfer of ICU patients from the EC increase the workload and contribute to EC crowding.

Prevalence and Clinical Characteristics of Unintentional Ingestion of Marijuana in Children Younger Than 6 Years in States With and Without Legalized Marijuana Laws

OBJECTIVE

The aim of this study was to examine the relationship between state marijuana legalization and the rates of unintentional ingestions of marijuana in children younger than 6 years.

METHODS

This was a retrospective review of all marijuana ingestions in the National Poison Data System in children younger than 6 years between January 1, 2000, and July 31, 2017. Data analysis from NPDS included, age, sex, state and year of occurrence, clinical effects, therapies, health care facility utilization, and medical outcome. Population of children younger than 6 years was obtained from the US Census Bureau. Public records search provided state legal status of marijuana and year of state marijuana legalization.

RESULTS

From 2000 through 2008, there was no significant change in the annual number or rate of ingestions of marijuana in children younger than 6 years across the United States. Following 2009, there was mean annual increase of 27% per year, rising to 742 ingestions per year or 2.98 ingestions per 100,000 population, respectively, in 2017. More than 70% of all cases occurred in states with legalized marijuana. Of all pediatric patients, 54.6% received some form of hospital-based care, of which 7.5% required critical care. Pediatric patients experienced a wide range of symptoms from drowsiness and confusion, to seizures and coma. Medical treatments ranged from hydration therapy to sedation and intubation. Poison centers safely managed 23.4% of these pediatric cases by phone, without the need for hospital evaluation.

CONCLUSION

There was a strong association between the legalization of marijuana and ingestions of marijuana by children younger than 6 years.

Pediatric Fatalities Associated With Over-the-Counter Cough and Cold Medications

BACKGROUND AND OBJECTIVES

In 2008, over-the-counter cough and cold medications (CCMs) underwent labeling changes in response to safety concerns, including fatalities, reported in children exposed to CCMs. The objective of this study is to describe fatalities associated with exposures to CCMs in children <12 years old that were detected by a safety surveillance system from 2008 to 2016.

METHODS

Fatalities in children <12 years old that occurred between 2008 and 2016 associated with oral exposure to one or more CCMs were identified by the Pediatric Cough and Cold Safety Surveillance System. An expert panel reviewed all cases to determine the causal relationship between the exposure and death, if the intent of exposure was therapeutic, and if the dose was supratherapeutic. Other contributing factors related to the child's death were also identified as part of a root cause analysis.

RESULTS

Of the 180 eligible fatalities captured during the study period, 40 were judged by the expert panel to be either related or potentially related to the CCM. Of these, the majority (n = 24; 60.0%) occurred in children <2 years old and involved nontherapeutic intent (n = 22; 55.0%). The most frequently involved index ingredient was diphenhydramine (n = 28; 70.0%). In 6 cases (n = 6; 15.0%), the CCM was administered to murder the child. In another 7 cases (n = 7; 17.5%), death followed the intentional use of the CCM to sedate the child.

CONCLUSIONS

Pediatric fatalities associated with CCMs occurred primarily in young children after deliberate medication administration with nontherapeutic intent by a caregiver.

Household cleaning products poisoning in a pediatric emergency center: A 10- year cross-sectional study and literature review

BACKGROUND

Poisoning by household cleaning products(HCPs) is common in children. Some HCPs are toxic and may cause severe complications. We assessed HCP poisonings treated in a pediatric emergency department(PED).

METHODS

This was a retrospective study of patients aged under 18 years with HCP poisoning admitted to the largest PED in Taiwan from 2011 to 2020 were recruited.

RESULTS

The records over a 10-year period from 103 children admitted to the PED because of HCP poisoning(70 boys [68%] and 33 girls [32%]), mean age 3.54 years(standard deviation [SD] = 3.15 years) were evaluated. Most poisonings were unintentional(99%, n = 102) and occurred at home(96%, n = 99). The HCPs included alkaline(74%, n = 76), acidic(25%, n = 26), and neutral(1%, n = 1) agents. Most were orally ingested(86%, n = 89). Panendoscopy was performed in 25 patients(24%), and the endoscopic(Zargar) grade was used to determine the severity of injury. Medications(steroids [9%, n = 9], antibiotics [10%, n = 10], or antacids [30%, n = 23]) were prescribed. Alkaline HCP ingestion induced severe esophageal injury(p = 0.04) and esophageal stricture(p = 0.04). Five patients(5%) exhibited esophageal strictures and required balloon dilation. On multivariate analysis, alkaline HCP ingestion(p = 0.04), severe esophageal caustic injury(Zargar grade ≥ 3) (p < 0.001), and medications(steroids [p < 0.001], antibiotics [p < 0.001], and antacids [p = 0.001]) were associated with esophageal stricture.

CONCLUSION

Alkaline HCP ingestion and severe esophageal caustic injury(Zargar grade ≥ 3) were associated with esophageal stricture. Physicians tended to prescribe medications(steroids, antibiotics, or antacids) for patients with severe esophageal injuries to reduce the risk of esophageal stricture. The usefulness of these medications requires further study.

Letter to the editor regarding the article "The global distribution of acute unintentional pesticide poisoning: estimations based on a systematic review"

We read with interest the article entitled “The global distribution of acute unintentional pesticide poisoning: estimations based on a systematic review”. We wholeheartedly agree that it is important to evaluate the extent of this issue. We would like to understand the numbers provided in this article, which appear to overestimate the global burden of pesticide poisonings. We also feel that addressing the benefits of these chemistries is important for a complete evaluation.

Epidemiological Characteristics of Sedative-Hypnotics and Opioid Painkillers at High-Frequency Exposure

Drug poisoning has a high incidence and serious consequences in medical institutions; its epidemiological characteristics also directly affect the changes in national laws and policies and the implementation of local management policies. Chinese statistics on drug-related abnormal death cases generally come from judicial appraisal centers and medical units. However, due to differences in work content and professional restrictions, there are differences in information management forms, which makes it difficult for appraisers to conduct a professional and systematic analysis of drug-related cases. This article focuses on the analysis of epidemiological characteristics of sedative-hypnotics and opioid painkillers and their exposure patterns in cases of poisoning death by analyzing the annual report of the American Association of Poison Control Center, combined with the characteristics of drug exposure in China.