Activated charcoal for acute overdose: a reappraisal

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

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

Cyanide toxicity secondary to apricot (Prunus armeniaca) kernel meal ingestion in a canine

Cyanide is one of the most rapidly acting, lethal poisons in human and veterinary medicine. This case report discusses a novel case of cyanide toxicity from apricot (Prunus armeniaca) kernel ingestion in a canine and alternative treatment modalities. A 9.5-year-old female spayed Golden Retriever presented for vomiting and collapse after ingestion of apricot kernel meal. Laboratory findings, including a high anion gap metabolic acidosis with severe hyperlactatemia, clinical signs, and known ingestion of apricot kernels, were suggestive of cyanide toxicity. The dog was treated with crystalloid and synthetic colloids for stabilization and antidote therapy with hydroxocobalamin. The dog's metabolic acidosis and hyperlactemia worsened despite antidote therapy, and the dog progressed to CPA during gastric decontamination efforts. The dog did not respond to CPR efforts. This report will review the mechanism of cyanide toxicity, treatment options, and considerations for future cases.

Prophylactic Oral Application of Activated Charcoal Mitigates Acute Campylobacteriosis in Human Gut Microbiota-Associated IL-10-/- Mice

The incidence of human Campylobacter jejuni infections is increasing worldwide. It is highly desirable to prevent campylobacteriosis in individuals at risk for severe disease with antibiotics-independent non-toxic compounds. Activated charcoal (AC) has long been used as an anti-diarrheal remedy. Here, we tested the disease-mitigating effects of oral AC versus placebo in human gut microbiota-associated (hma) IL-10-/- mice starting a week prior to C. jejuni infection. On day 6 post-infection, the gastrointestinal C. jejuni loads were comparable in both infected cohorts, whereas campylobacteriosis symptoms such as wasting and bloody diarrhea were mitigated upon AC prophylaxis. Furthermore, AC application resulted in less pronounced C. jejuni-induced colonic epithelial cell apoptosis and in dampened innate and adaptive immune cell responses in the colon that were accompanied by basal concentrations of pro-inflammatory mediators including IL-6, TNF-α, IFN-γ, and nitric oxide measured in colonic explants from AC treated mice on day 6 post-infection. Furthermore, C. jejuni infection resulted in distinct fecal microbiota shift towards higher enterobacterial numbers and lower loads of obligate anaerobic species in hma mice that were AC-independent. In conclusion, our pre-clinical placebo-controlled intervention study provides evidence that prophylactic oral AC application mitigates acute murine campylobacteriosis.

Is the whitening effect of charcoal-based dentifrices related to their abrasive potential or the ability of charcoal to adsorb dyes?

OBJECTIVES

To evaluate if tooth color alteration of activated charcoal-based dentifrices may be attributed to the dye adsorption potential of charcoal (chemical action - C - slurry only) or to the association of dye adsorption with abrasion (chemo-mechanical action - CM- slurry/toothbrushing). Potential adverse effects in surface roughness, gloss, and wear were also assessed.

METHODS

Bovine enamel/dentin specimens were randomly allocated into the groups according to treatments and test model (n = 15): deionized water (negative control- NC); Colgate Maximum Anticaries Protection (conventional toothpaste- positive control- PC); Colgate Luminous White Activated Charcoal (LW); Oral-B 3D White Therapy Charcoal (WT); Curaprox Black is White (BW); Dermavita Whitemax (Activated charcoal powder- WP). Specimens were exposed to the C or CM models, in 28-day staining-treatment cycling. Color change (ΔE00), whiteness index (ΔWID), percentage of alteration of surface roughness (%Raalt), and gloss (%GUalt) were calculated. Additional specimens (n = 9) were indented with a Knoop diamond and subjected to 100,000 abrasion cycles. Enamel wear was determined by calculating the decrease in indentations geometry. Data were analyzed by ANOVA/Tukey tests (α = 0.05).

RESULTS

The CM-model produced lower color change (staining) than C (p = 0.0001). PC, LW, WT, BW, and WP showed similar color results for both models, differing from NC (p < 0.05).%Ra and%GU did not differ among the C-model groups (p > 0.05) and WP exhibited the highest variation (%Ra and%GU) under CM-model. Enamel wear values were lowest in the NC and PC groups, intermediate for LW, WT, BW, and highest for the WP (p < 0.05).

CONCLUSION

Activated charcoal-based dentifrices have a similar ability to minimize tooth staining as the conventional toothpaste, with increased enamel wear potential in the long term (after 100,000 cycles). The activated charcoal powder damaged the enamel surface, showing a higher deleterious effect on enamel roughness, gloss, and wear.

CLINICAL SIGNIFICANCE

Dentifrices containing activated charcoal do not provide superior results to minimize tooth staining compared to conventional toothpaste. Charcoal powder should be used with caution because it promotes higher superficial alterations on the enamel surface.

Sugarcane bagasse biochar enhances the growth parameters, haematological parameters, and enzyme activities of genetically improved farmed tilapia (GIFT) reared in inland saline water

In the present scenario, waste management, especially agro-waste, is one of the major challenges. India is an agrarian country and the economy depends on agriculture and a huge amount of agro-wastes are generated. In this study, biochar was prepared from paddy straw and sugarcane bagasse and was used in the feed of genetically improved farm tilapia (GIFT) at 0.5% (w/w) basis to study its effect on growth and haematological parameters. An experiment was carried out in triplicate in 500-l capacity FRP tanks comprising two treatments and one control. Tanks were filled with inland saline soil to maintain 25-cm soil's bed and water with 12 ppt salinity. A total of 22 fish having an average length of 5.14 ± 0.07 cm and weight of 4.8 ± 0.05 g were stocked in each tank; the fish were fed at apparent satiation level, twice daily for 45 days. It was observed that growth parameters like SGR% (specific growth rate), weight gain (WG%), and feed conversion ratio (FCR) were significantly improved (p < 0.05) than the control. Biochar-enriched feed also significantly improved the haematological parameters like red blood cell (RBC), white blood cell (WBC), haemoglobin (Hb) haematocrit % (HCT), mean cell haemoglobin concentration (MCH), and MCV (mean cell volume) in treatment groups than the control. Feeding biochar as feed additives was also found to decrease catalase (CAT) and enhanced amylase and lipase activities in treatments as compared to control (p < 0.05). It can be concluded that the application of biochar as a feed additive enhanced the growth and overall health of the fish, and it can enhance fish production. However, biochar from sugarcane bagasse was found to be more effective than the paddy straw biochar in the diet of tilapia (GIFT).

Effect of Taste Additives on the Palatability of Activated Charcoal: a Systematic Review

INTRODUCTION

Activated charcoal is a decontaminating agent used for acute intoxication. It can be mixed with taste additives to overcome its poor palatability. Our purpose was to evaluate the taste additives used to improve activated charcoal's palatability.

METHODS

We conducted a systematic review of comparative studies on taste additives used to improve activated charcoal's palatability. We searched PubMed, Embase, Web of Science, Cochrane, and CINAHL. We included controlled trials and observational studies that evaluate the effect of at least one taste additive, compared with activated charcoal alone. Our primary outcome was palatability. Our secondary outcomes included treatment adherence, adsorption efficacy, and adverse events. The risk of bias was assessed using the Quality Assessment Tool for Quantitative Studies.

RESULTS

Among 38 eligible articles, seven observational studies and three crossover clinical trials met our inclusion criteria. The risk of bias was found to be high for seven studies and intermediate for three others. The preferred flavoring agents were cola and chocolate milk for children, and sweetening agents for adults. All taste additives studied seemed to improve activated charcoal's palatability, except for yogurt (n = 1). The addition of bentonite, sorbitol, carboxymethylcellulose, or yogurt showed no impact on the in-vivo adsorption capacity of activated charcoal, whereas the results were inconclusive for chocolate. No meta-analysis was performed due to insufficient data.

CONCLUSION

Strategies to improve activated charcoal's palatability seem to enhance the taste. Descriptive data are in favor of a limited impact on activated charcoal's adsorption capacity when adding binding agents or sweeteners.

TRIAL REGISTRATION ON PROSPERO

This review is registered as PROSPERO CRD42019135092.

Relative dentin and enamel abrasivity of charcoal toothpastes

OBJECTIVES

Very little data are known about charcoal toothpastes. The aim of this study was to counteract the missing data by determining the relative dentin abrasivity (RDA) and relative enamel abrasivity (REA) values of charcoal toothpastes.

METHODS

Radioactively charged dentin and enamel samples were randomly divided into groups of eight specimens. Each group was brushed with two of total 12 charcoal toothpaste slurries and with a standard abrasive with a known RDA and REA value. The measured radioactivity in counts per minute within the slurries corresponds to the amount of dentin or enamel abraded. RDA and REA values of the charcoal toothpastes were expressed relative to the known value of the standard slurry.

RESULTS

The RDA and REA values of the charcoal toothpastes have a broad range of 24-166 and 0-14, respectively.

CONCLUSIONS

The RDA and REA values do not differ significantly from previously tested commercially available toothpastes. However, the lack of fluoride compounds in many of the investigated charcoal toothpastes can have a less beneficial effect for the consumers. It is very important to educate patients accordingly.

Disagreements Between Calorimetric and Van't Hoff Enthalpies of Adsorption: A New Langmuir-like Model to Account for the Effect of Solvent Displacement Stoichiometry

The reported inconsistencies between calorimetry and the van't Hoff equation hinder the utility of thermodynamics in pharmaceutical research. In ligand binding or adsorption assays, it is believed that the van't Hoff equation falls short because of the lack of stoichiometric treatment in the equilibrium constant. A new modified Langmuir-Like equation that accounts for the stoichiometry of solute adsorption and solvent displacement is proposed in this work. The performance of the model was evaluated by studying the adsorption of phenobarbital from aqueous solutions by commercial activated carbon. The amount of water occupying the adsorption sites was estimated by graphical analysis of the 'knee point' of water-vapor adsorption isotherms and was found to correlate well with the relative percentage of hydroxyl and carbonyl surface groups. It was found that one phenobarbital molecule displaces 2-6 water molecules from the adsorption site. It is shown that adsorption enthalpy was not affected by the adjustment for stoichiometry, supporting the notion that the van't Hoff enthalpy is intrinsic and is independent of the stoichiometry of solvent displacement in Langmuir-based binding. The widely reported disparities between the van't Hoff and calorimetric enthalpies are unlikely to be from a stoichiometric origin.

Uremic pruritus: pathophysiology, clinical presentation, and treatments

Uremic pruritus is one of the most common and bothersome symptoms in patients with end-stage renal disease. Most patients with uremic pruritus experience a prolonged and relapsing course and significant impairments of quality of life. The pathophysiology of uremic pruritus is not completely understood. A complex interplay among cutaneous biology and the nervous and immune systems has been implicated, with the involvement of various inflammatory mediators, neurotransmitters, and opioids. Uremic pruritus treatment outcomes are often unsatisfactory. Clinical trials have mostly been small in scale and have reported inconsistent results. Recent evidence shows that gabapentinoids, nalfurafine, and difelikefalin are effective for relieving uremic pruritus in hemodialysis patients. This review provides an overview of the epidemiology and proposed mechanisms of uremic pruritus, then highlights the manifestations of and clinical approach to uremic pruritus. Current evidence regarding treatment options, including topical treatments, treatment of underlying disease, phototherapy, and systemic treatments, is also outlined. With a better understanding of uremic pruritus, more therapeutic options can be expected in the near future.

Pesticide exposure and poisoning in Brazil: Outcome severity, clinical manifestations and management of cases reported to a poison control center

This work aimed to identify variables associated with increased risk of outcome severity as well as to describe clinical manifestations/symptoms and management of pesticide-related cases reported to a poison center in Brazil. An increased risk of more severe outcomes was observed when exposures occurred in rural areas, involved suicide attempts and moderately to extremely hazardous pesticides. Clinical manifestations with higher frequencies included vomiting, nausea, sialorrhea, headache, miosis and sweating. From the treatment initially applied to the patient, 51.91% encompassed gastric lavage, but this procedure was only recommended in 20.01% of cases by the CIATox. Identifying risk factors associated with poor outcome, describing clinical manifestations, and contrasting initial treatment measures adopted against those recommended by the Poison Center can help determine diagnosis, prognosis and ensure appropriate clinical interventions are used in cases of pesticide poisoning.

Effect of 16% Carbamide Peroxide and Activated-Charcoal-Based Whitening Toothpaste on Enamel Surface Roughness in Bovine Teeth: An In Vitro Study

Background: Activated charcoal is a nanocrystalline form of carbon with a large specific surface area and high porosity in the nanometer range, having consequently the capacity to absorb pigments, chromophores, and stains responsible for tooth color change, while carbamide peroxide is unstable and breaks down immediately upon contact with tissue and saliva, first dissociating into hydrogen peroxide and urea and subsequently into oxygen, water, and carbon dioxide. Therefore, the aim of the present study was to assess the effect of 16% carbamide peroxide and activated-charcoal-based whitening toothpaste on enamel surface roughness in bovine teeth. Materials and Methods: The present experimental in vitro, longitudinal, and prospective study consisted of 60 teeth randomly distributed in six groups: A: artificial saliva, B: conventional toothpaste (Colgate Maximum Protection), C: whitening toothpaste with activated charcoal (Oral-B 3D White Mineral Clear), D: 16% carbamide peroxide (Whiteness Perfect 16%), E: 16% carbamide peroxide plus conventional toothpaste (Whiteness Perfect 16% plus Colgate Maximum Protection), and F: 16% carbamide peroxide plus whitening toothpaste with activated charcoal (Whiteness Perfect 16% plus Oral-B 3D White Mineral Clear). Surface roughness was assessed with a digital roughness meter before and after each treatment. For the statistical analysis, Student’s t test for related samples was used, in addition to the ANOVA test for one intergroup factor, considering a significance level of p < 0.05. Results: The surface roughness variation of bovine tooth enamel, before and after application of bleaching agent, was higher in groups of whitening toothpaste with activated charcoal (0.200 µm, Confidence Interval (CI): 0.105; 0.296 µm) and 16% carbamide peroxide plus whitening toothpaste with activated charcoal (0.201 µm, (CI): 0.092; 0.309 µm). In addition, bovine teeth treated with conventional toothpaste (p = 0.041), whitening toothpaste with activated charcoal (p = 0.001), and 16% carbamide peroxide plus whitening toothpaste with activated charcoal (p = 0.002) significantly increased their surface roughness values. On the other hand, significant differences were observed when comparing the variation in surface roughness between the application of artificial saliva (control) and the whitening toothpaste with activated charcoal (p = 0.031), and the 16% carbamide peroxide plus whitening toothpaste with activated charcoal (p = 0.030). Conclusion: The use of whitening toothpaste with activated charcoal and in combination with 16% carbamide peroxide significantly increased enamel surface roughness in bovine teeth.

Recent Advances in Mesoporous Materials and Their Biomedical Applications

Since the beginning of civilization, porous materials have been used for medical purposes [...].

Activated Carbon for Drug Delivery from Composite Biomaterials: The Effect of Grinding on Sirolimus Binding and Release

Activated carbon (AC) could be potentially useful as a drug carrier in fiber polymer scaffolds destined for prolonged drug delivery. To be introduced, AC must be ground into smaller-sized particles to be introduced in scaffolds, as most biocompatible scaffolds consist of fibers with a diameter of less than 1 µm. In this study, the adsorption of sirolimus (SRL) from phosphate-buffered saline (PBS) solution and blood plasma (BP) onto AC of AX-21 type, as well as the release of SRL from AC depending on its fragmentation, were studied. Two-stage grinding of the AC, first with a ball mill, and then with a bead mill, was performed. Grinding with a bead mill was performed either in water or in polyvinylpyrrolidone to prevent aggregation of AC particles. Dynamic light scattering and scanning electron microscopy (SEM) demonstrated that the size of the particles obtained after grinding with a ball mill was 100–10,000 nm, and after grinding with a bead mill, 100–300 nm. Adsorption in PBS was significantly higher than in BP for all fractions, and depended on SRL concentration. The fraction obtained after grinding with a ball mill showed maximal SRL adsorption, both in PBS and BP, and slow SRL release, in comparison with other fractions. The 100–300 nm AC fractions were able to adsorb and completely release SRL into BP, in contrast to other fractions, which strongly bound a significant amount of SRL. The data obtained are to be used for controlled SRL delivery, and thus in the modification of drug delivery in biological media.

Intensivmedizinische Versorgung von Patienten mit akuter Intoxikation in Deutschland – ein Rückblick über 20 Jahre

Hintergrund

Die vorliegende Studie präsentiert ein Kollektiv akut intoxikierter Patienten, die in den letzten 2 Jahrzehnten auf eine medizinische Intensivstation eines tertiären Versorgungszentrums in Deutschland aufgenommen wurden.

Ziel der Arbeit

Das Ziel der Studie bestand darin, einen Überblick zur akuten Intoxikation als relevantes intensivmedizinisches Krankheitsbild und hiermit assoziierte klinische Charakteristika sowie die Prognose der betroffenen Patienten zu bieten.

Material und Methoden

Die Studienkohorte umfasst 1030 Patienten, die in den Jahren1999–2019 aufgrund einer akuten Vergiftung auf die medizinische Intensivstation der Uniklinik RWTH Aachen aufgenommen wurden. Demographische und klinische Merkmale sowie das klinische Management wurden detailliert analysiert und zwischen alters- und geschlechtsspezifischen Untergruppen verglichen.

Ergebnisse

Suizidversuche stellten die häufigste Ursache für die intensivmedizinische Aufnahme intoxikierter Patienten dar. Insbesondere führten Medikamente, v. a. Antidepressiva, zu einer akuten Vergiftung. Die Substanzen variierten hierbei je nach Geschlecht und Alter der betroffenen Patienten. In der Subgruppe der älteren Patienten stellten Benzodiazepine die am häufigsten verwendeten Substanzen dar. 286 Patienten (28 %) entwickelten ≥ 1 Organversagen. Die Gesamtmortalität betrug 2,6 %. Im Vergleich der ersten (1999–2009) mit der zweiten Dekade (2010–2019) des Beobachtungszeitraums zeigte sich ein Trend zu einer häufigeren Einnahme von Antidepressiva und Alkohol, während die Verwendung von Benzodiazepinen rückläufig war.

Diskussion

Obwohl die Gesamtmortalität im beobachteten Kollektiv gering ist, repräsentieren akut vergiftete Patienten fast 10 % aller Einweisungen auf die Intensivstation und beanspruchen insbesondere in Zeiten begrenzter Intensivkapazitäten wertvolle Ressourcen.

Microbial approaches for the assessment of toothpaste efficacy against oral species: A method comparison

Antibacterial properties of toothpastes enable chemical plaque control in limited‐access tooth regions that are mechanically not sufficiently reached by toothbrushes. Therefore, this study aimed to compare different microbial methods to assess antimicrobial toothpaste properties and evaluate different toothpastes in terms of their antibacterial efficacy against different oral microorganisms in an in vitro setting. Six toothpaste suspensions with varying antibacterial supplements were applied to a multispecies biofilm model (Actinomyces oris, Candida albicans, Fusobacterium nucleatum, Streptococcus oralis, and Streptococcus mutans) as well as to each microorganism. A culture method was used to assess the anti‐biofilm effects and two different agar diffusion assays were performed for testing the antimicrobial effect on each microorganism. The measurements of the culture and diffusion analyses were statistically normalized and compared and toothpastes were ranked according to their antimicrobial efficacy. The results of both agar diffusion assays showed a high correlation across all tested species (Spearman correlation coefficients ρ_s > 0.95). The results of the multispecies biofilm model, however, substantially differed in its assessment of antibacterial properties (ρ_s ranging from 0.22 to 0.87) compared to the results of both diffusion assays. Toothpastes with amine fluoride (with and without stannous fluoride), and toothpastes with triclosan resulted in the highest antimicrobial efficacy. Activated carbon supplements in toothpastes were comparable in their antimicrobial action to the negative control NaCl. The appropriate selection of a broad range of oral microorganisms seems crucial when testing the chemical impact of toothpaste and toothpaste supplements.

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.

Prevalence of medically unsupervised activated charcoal use a cause for concern in celiac disease?

BACKGROUND

Celiac disease is an autoimmune disorder that causes an intolerance to gluten. Owing to hidden sources, lack of clear labeling, and cross-contamination, it is not uncommon for individuals with celiac disease to inadvertently ingest gluten. A strict gluten-free diet is the only treatment.

OBJECTIVES

The purpose of this study was to identify the frequency of activated charcoal use in celiac disease as a purported remedy despite the lack of literature on the safety and efficacy of the practice and to elucidate the manner in which using activated charcoal as a treatment for acute gluten ingestion is being communicated.

METHODS

Using a descriptive study design, a Web-based survey was sent to members of the celiac disease community via social media pages for voluntary participants 18 years and older diagnosed with celiac disease. Participants were stratified into 3 major groups: (1) those who had heard of using activated charcoal as a remedy to counteract gluten ingestion and used it, (2) those who had heard of using activated charcoal but had not used it, and (3) those who had not heard of using activated charcoal.

RESULTS

In subjects with celiac disease, 424 of 1613 respondents (26%) had heard of using activated charcoal as a potential remedy for gluten ingestion, and 12% had used it. The top source of information regarding any general information including remedies for maladies related to celiac disease was social media networks 72.3% (879/1613). Of those who had used activated charcoal, 122 participants (61.3%) reported subjectively feeling a reduced severity of symptoms.

CONCLUSION

Pharmacists should be aware of the off-label use of activated charcoal for accidental gluten ingestion in celiac disease. Pharmacists should educate patients with celiac disease that there is not sufficient evidence to support the use of activated charcoal.

Activated Charcoal and Poisoning: Is It Really Effective?

BACKGROUND

This study aims to compare the poisoned patients who could not be administered activated charcoal because of its unavailability with the poisoned patients who were administered charcoal in the later period and to reveal the results about its effectiveness.

STUDY QUESTION

Is the use of activated charcoal effective against poisoning caused by oral medication?

STUDY DESIGN

This retrospective cohort study with historical control was planned at a tertiary hospital. Patients older than 18 years were admitted to the emergency department because of oral drug poisoning during the study periods. A total of 1159 patients who were not given activated charcoal and 877 patients who were given activated charcoal were included in this study.

MEASURES AND OUTCOMES

The frequency of clinical findings secondary to the drug taken, the frequency of antidote use, the frequency of intubation, and the hospitalization length were determined as clinical outcome parameters.

RESULTS

There was no statistically significant difference in the development of central nervous system findings, cardiovascular system findings, frequency of intubation, and blood gas disorders, as well as the length of hospitalization periods according to the activated charcoal application. Hepatobiliary system findings and electrolyte disturbances were found to be less common in patients given activated charcoal. The frequency of tachycardia, speech impairment, coma, and respiratory acidosis was found to be statistically higher in patients who were administered activated charcoal. The hospitalization period of the patients who were given activated charcoal was longer in patients with drug findings; however, there was no difference in the hospitalization periods of the patients who were given an antidote.

CONCLUSIONS

The use of activated charcoal in poisoned patients may not provide sufficient clinical benefits. However, clinical studies with strong evidence levels are needed to determine activated charcoal's clinical efficacy, which is still used as a universal antidote.

Disease-Alleviating Effects of Peroral Activated Charcoal Treatment in Acute Murine Campylobacteriosis

Foodborne Campylobacter jejuni infections are on the rise and responsible for worldwide serious health issues. Increasing resistance of C. jejuni strains against antimicrobial treatments, necessitates antibiotics-independent treatment options for acute campylobacteriosis. Activated charcoal (AC) constitutes a long-known and safe compound for the treatment of bacterial enteritis. In this preclinical intervention study, we addressed potential anti-pathogenic and immune-modulatory effects of AC during acute experimental campylobacteriosis. Therefore, microbiota-depleted IL-10^-/- mice were infected with C. jejuni by gavage and challenged with either AC or placebo via the drinking water starting on day 2 post-infection. On day 6 post-infection, AC as compared to placebo-treated mice did not only harbor lower intestinal pathogen loads but also presented with alleviated C. jejuni-induced clinical signs such as diarrhea and wasting symptoms. The improved clinical outcome of AC-treated mice was accompanied by less colonic epithelial cell apoptosis and reduced pro-inflammatory immune responses in the intestinal tract. Notably, AC treatment did not only alleviate intestinal, but also extra-intestinal and systemic immune responses as indicated by dampened pro-inflammatory mediator secretion. Given the anti-pathogenic and immune-modulatory properties of AC in this study, a short-term application of this non-toxic drug constitutes a promising antibiotics-independent option for the treatment of human campylobacteriosis.

Approach to Toxicologic Emergencies

Equine toxicologic emergencies are relatively uncommon but can cause significant morbidity and mortality in a group of comanaged horses. The field veterinarian's role is to triage the situation, as well as the individual animal. Individual patient stabilization should focus on support of essential organ functions, providing time for treatments to have an effect or for elimination of the toxicant. Decontamination procedures can follow patient stabilization, if appropriate. Antidotes are often not available or feasible for equine intoxications. The field veterinarian should emphasize triage and stabilization before referral and on-site identification and collection of diagnostic samples to support the diagnosis.

The Individualized Management Approach for Acute Poisoning

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

Pharmacobezoar After Venlafaxine and Oxazepam Overdose: How Pharmacokinetics Could Help?-A Grand Round

ABSTRACT

The authors present here a case of a pharmacobezoar after drug overdose, diagnosed using multiple blood samples for TDM. This grand round highlights the importance of a dialog between a clinician and a TDM consultant for the optimal care of a patient.

Salicylate toxicity from chronic bismuth subsalicylate use

A 79-year-old man presented to the emergency department with a 1-week history of worsening confusion, falls and hearing impairment. An initial workup for infectious, metabolic and structural causes was unrevealing. However, further history discovered that he had been ingesting one to two bottles of Pepto-Bismol (bismuth subsalicylate) daily for gastro-oesophageal reflux symptoms. On his second day of admission, the plasma salicylate concentration was 2.08 mmol/L (reference range 1.10-2.20 mmol/L), despite no sources of salicylate in hospital. He was diagnosed with chronic salicylate toxicity and Pepto-Bismol use was discontinued. The patient was treated supportively with isotonic intravenous fluids only and plasma salicylate concentration fell to less than 0.36 mmol/L. Concurrently, all his symptoms resolved. This case highlights the potential adverse effects of over-the-counter medications. The diagnosis of chronic salicylate toxicity is challenging, specifically in the elderly and in undifferentiated presentations, as it can be missed if not suspected.

Pattern of food, drug and chemical poisoning in Qassim region, Saudi Arabia from January 2017 to December 2017

Background

Poisoning has become a widespread and dangerous phenomenon worldwide. The purpose of our study was to determine and analyze the pattern of poisoning cases induced with food, drugs, and chemicals reported to the Department of Environmental and Occupational Health in Qassim province in the Kingdom of Saudi Arabia. The study also evaluated the correlation of demographic variables such as age, type of toxicity and geographical distribution associated with poisoning in Qassim province.

Methods

This retrospective cross-sectional study was performed on 381 cases of poisoning. The data was collected from Jan 2017 to Dec 2017 and revealed that out of 381 cases, 120 have food poisoning (65 % females and 35 % males), 180 have drug poisoning (55.56 % females and 44.44 % males), whereas 81 cases have chemical poisoning (41.98 % female and 58.02 % male). Data were statistically analyzed using SPSS/PC statistical package. The study revealed that the most common agents involved in acute poisoning were drugs (47.25 %), especially analgesics such as Paracetamol (Acetaminophen), followed by antipsychotic drugs. Food poisoning was the second acute poisoning with (31.40 %). Finally, chemical poisoning involved in acute poisoning with 21.20 % of cases reported household products accomplished strongest bleach (chlorines)(Clorox®) and insecticides were the secondary source for chemical poisoning.

Biomass-derived nanocarbon materials for biological applications: challenges and prospects

Biomass-derived nanocarbons (BNCs) have attracted significant research interests due to their promising economic and environmental benefits. Following their extensive uses in physical and chemical research domains, BNCs are now growing in biological applications. However, their practical biological applications are still in their infancy, requiring critical evaluations and strategic directions, which are provided in this review. The carbonization of biomass sources and major types of BNCs are introduced, encompassing carbon nanodots, nanofibres, nanotubes, and graphenes. Next, essential biological uses of BNCs, antibacterial/antibiofilm materials (nanofibres and nanodots) and bioimaging agents (predominantly nanodots), are summarized. Furthermore, the future potential of BNCs, for designing wound dressing/healing materials, water and air disinfection platforms, and microbial electrochemical systems, is discussed. We reach the conclusion that a crucial challenge is the structural control of BNCs. Furthermore, a key knowledge gap for realizing practical biological applications is the lack of systematic comparisons of BNCs with nanocarbons of synthetic origin in the current literature. Although we did not attempt to perform an exhaustive literature survey, the evaluation of the existing results indicates that BNCs are promising as easily accessible materials for various biomedically and environmentally relevant applications.

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

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

Accidental Overdose of Pergolide (Prascend) Followed by Loss of Appetite, Tachycardia, and Behavioral Abnormalities in a Pony Mare

A 26-year-old pony mare (ca. 180 kg bodyweight) was presented as an emergency because it had erroneously received 110 times its standard dose of pergolide (Prascend) per os approximately 4 hours earlier. Clinical examination initially was normal except tachycardia of 52 beats/min. The pony was treated symptomatically with paraffin oil and activated charcoal per nasogastric tube to prevent further systemic absorption and accelerate intestinal excretion of the pergolide. Furthermore, the pony received 400 mg of dopamine antagonist azaperone (Stresnil) intramuscularly (i.m.) followed by 80 mg every 6 hours twice i.m. and then 60 mg every 6 hours twice i.m. In addition, 40 mg verapamil (Verapamil-ratiopharm) was given every 4 hours per os for two days, followed by 40 mg every 6 hours for another 5 days. The pony was closely monitored clinically. It remained bright and alert with heart rate returning to normal within one day. The only abnormalities noticed 24 hours after ingestion of the pergolide overdose were a decreased appetite and anxiety, possibly a dopaminergic central nervous effect. Over the next days, appetite returned and anxiety disappeared. Overdosing pergolide is considered very rare and to the authors' knowledge this is the first report with a severe overdose of pergolide (Prascend). As accidental drug overdosing is a common error in medicine, it is important to know about possible side effects and how to react in cases like this.

Charcoal: An ancient material with a new face

Activated charcoal has become popular in the cosmetic industry and is found in a variety of products, including facial cleansers and soaps. For centuries, charcoal has been used as an antidote for poisonings, but now companies claim that charcoal-containing products can treat acne, dandruff, and others; however, clinical evidence does not support these claims. Patients should be counseled that the use of activated charcoal is generally safe but advised that there is a lack of evidence to support its exfoliative or anti-aging abilities.

The Use of Activated Charcoal to Treat Intoxications

BACKGROUND

In 2016, according to the German Federal Statistical Office, 178 425 cases of intoxication (poisoning) were treated in German hospitals. The poison control centers in the German-speaking countries gave advice in a total of 268 787 instances of poisoning in that year, and use of activated charcoal was recommended in 4.37% of cases. The application of activated charcoal plays a major role in both primary and secondary detoxification. This article serves as an overview of the mechanism of action, indications, contraindications, modes of application, and dosing of activated charcoal.

METHODS

This review is based on pertinent publications retrieved by a selective search in PubMed. The opinions of experts from the poison control centers in the German-speaking countries were considered in the interpretation of the data.

RESULTS

The administration of activated charcoal is indicated to treat moderately severe to life-threatening intoxication. It should be carried out as soon as possible, within the first hour of the ingestion; timed-release preparations can be given up to 6 hours after the ingestion. An important contraindication is impaired consciousness with the danger of aspiration in a patient whose air- way has not yet been secured. Activated charcoal is ineffective or inadequately effective in cases of poisoning with acids or bases, alcohols, organic solvents, inorganic salts, or metals. The proper dosage consists of an amount that is 10 to 40 times as much as that of the intoxicating substance, or else 0.5-1 g/kg body weight in children or 50 g in adults. Repeated application is indicated for intoxications with agents that persist for a longer time in the stomach and for intoxications with timed-release drugs or drugs with a marked enterohepatic or entero-enteric circulation. The routine combination of activated charcoal with a laxative is not recommended.

CONCLUSION

Even though intoxications are common, there is still no internationally valid guideline concerning the administration of activated charcoal. A precise analysis of the risks and benefits is needed for each administration, and a poison control center should be consulted for this purpose.

The Effect of a Charcoal-based Powder for Enamel Dental Bleaching

Clinical Relevance

Charcoal based-powders are not effective for dental bleaching.

SUMMARY

Charcoal-based dentifrices for dental whitening are a novelty in the market. Manufacturers claim that such charcoal-based products have whitening, remineralization, antimicrobial, and antifungal properties of charcoal in such products. However, there is no substantial scientific evidence for these claims. This laboratory randomized study was designed to evaluate the whitening properties of a charcoal-based toothpowder. A total of 45 bovine dental enamel discs were randomly distributed into three groups (n=15): group 1, mechanical brushing with a 1450-ppm F toothpaste (control group); group 2, mechanical brushing with an activated charcoal-based powder; group 3, bleaching per the standard protocol using 10% carbamide peroxide. The surface roughness and color of each specimen were analyzed at baseline and after 14 days of experiment. The surface of one randomly selected specimen from each group was examined using a scanning electron microscope (SEM). The Kruskal-Wallis test was used to compare groups at a significance level of 5%. Only group 3 promoted a statistically significant effect on ΔE compared with groups 1 and 2 (p&lt;0.001 and p=0.003, respectively). No statistically significant difference was found between groups for surface roughness (p&gt;0.05). SEM revealed a more irregular surface in group 1 specimens compared with group 2 and 3 specimens. The charcoal-based powder did not seem to have any bleaching effect.

Resolving DOAC interference on aPTT, PT, and lupus anticoagulant testing by the use of activated carbon

BACKGROUND

Direct oral anticoagulants (DOACs) affect laboratory coagulations tests. Activated carbon (AC) can be used for adsorption of DOACs during acute human intoxications.

OBJECTIVES

This study evaluates whether AC can also be used to resolve DOAC interference on in vitro clotting tests (prothrombin time [PT], activated partial thromboplastin time [aPTT], and lupus anticoagulant [LA] assays).

PATIENTS/METHODS

Interference on PT, aPTT, Liquid anti-FXa, DTI, and LA screening/confirmation (SCT and dRVVT) was determined by spiking citrated plasma from 5 adult controls with 0, 20, 40, 80, 120, or 160 mg/mL AC. DOAC concentrations, PT, and aPTT were compared before and after AC addition to citrated plasma from patients receiving DOACs (n = 29), low molecular weight heparin (n = 10), and coumarin (n = 10) therapy. Samples from 69 LA screened patients were compared before and after AC addition.

RESULTS

A concentration of 20 mg/mL AC had the lowest interference and was selected for further experiments. After AC addition, all DOAC concentrations were below the limit of quantification in the 29 treated patients, except for 2 apixaban samples. AC removed DOAC interference on PT and aPTT but had no impact on results obtained during coumarin or low molecular weight heparin therapy. Of 15 LA samples with interference resulting from DOAC therapy, 14 samples became negative and 1 positive after AC addition. Interference from coumarin therapy was not resolved. All 19 LA negative samples remained negative. AC treatment of the negative pooled plasma was required to avoid false-negative LA results in 21 known LA-positive samples.

CONCLUSIONS

AC selectively removes DOAC interference on PT, aPTT, and LA assays.

An Eco- and User-Friendly Herbicide

The increasing use of pesticides in agriculture and gardening has caused severe deterioration to both the ecosystem and the health of users (human beings), so there is an urgent need for eco- and user-friendly pesticides. Among a variety of herbicides, paraquat (PQ), frequently used as an effective herbicidal agent worldwide, is well-known for its serious toxicity that has killed, and harmed, thousands of people and countless wildlife such as fish. Herein, we present a facile supramolecular formulation of PQ@cucurbit[7]uril (PQ@CB[7]), prepared by simply mixing PQ with equivalent (molar) CB[7] in water. With addition of CB[7], PQ's cellular uptake was dramatically inhibited. The reactive oxygen species (ROS) generation and the associated apoptosis otherwise induced by PQ in cellular models were both reduced, resulting in increased cellular viability. In a wildtype zebrafish model that is a typical fragile wildlife species in the ecosystem, the supramolecular formulation exhibited significantly reduced hepatotoxicity and increased survival rate, in comparison with those of the fish exposed to free PQ. In a mouse model that is clinically relevant to human being, the administration of PQ@CB[7] significantly alleviated major organ injuries and unusual hematological parameters that were otherwise induced by free PQ, resulting in a significantly increased survival rate. Meanwhile, this formulation maintained effective herbicidal activity that was equivalent to that of free PQ. Taken together, this facile supramolecular PQ formulation is providing not only an extremely rare example of an eco- and user-friendly herbicide that has been desired for decades but also a practical solution for green agriculture.

A Bifunctional Adsorber Particle for the Removal of Hydrophobic Uremic Toxins from Whole Blood of Renal Failure Patients

Hydrophobic uremic toxins accumulate in patients with chronic kidney disease, contributing to a highly increased cardiovascular risk. The clearance of these uremic toxins using current hemodialysis techniques is limited due to their hydrophobicity and their high binding affinity to plasma proteins. Adsorber techniques may be an appropriate alternative to increase hydrophobic uremic toxin removal. We developed an extracorporeal, whole-blood bifunctional adsorber particle consisting of a porous, activated charcoal core with a hydrophilic polyvinylpyrrolidone surface coating. The adsorption capacity was quantified using analytical chromatography after perfusion of the particles with an albumin solution or blood, each containing mixtures of hydrophobic uremic toxins. A time-dependent increase in hydrophobic uremic toxin adsorption was depicted and all toxins showed a high binding affinity to the adsorber particles. Further, the particle showed a sufficient hemocompatibility without significant effects on complement component 5a, thrombin-antithrombin III complex, or thrombocyte concentration in blood in vitro, although leukocyte counts were slightly reduced. In conclusion, the bifunctional adsorber particle with cross-linked polyvinylpyrrolidone coating showed a high adsorption capacity without adverse effects on hemocompatibility in vitro. Thus, it may be an interesting candidate for further in vivo studies with the aim to increase the efficiency of conventional dialysis techniques.

Left Ventricular Regional Wall Motion Abnormality in the Setting of Acute Loperamide Overdose

Loperamide is an inexpensive, over-the-counter antidiarrheal agent with emerging reports of overdose due to its opioid properties. Although it is considered by many patients to be safe, cardiotoxicity has been reported, prompting the United States Food and Drug Administration to release a warning regarding the arrhythmogenic potential of loperamide. We present a case of a 32-year-old male presenting in acute loperamide overdose and subsequent cardiac dysrhythmia with focal wall motion abnormalities on echocardiogram. This finding has not been previously reported in the literature and is unique in this clinical presentation. We also highlight the potential mechanisms for loperamide cardiotoxicity and its challenging management.

A rare case of small bowel obstruction secondary to activated charcoal administration

Intestinal obstruction is a rare complication of the administration of activated charcoal. We describe a 22-year-old patient who had received multiple-dose activated charcoal for carbamazepine intoxication. The patient presented with sudden-onset abdominal pain after discharge from the emergency room, and abdominal imaging examinations revealed findings consistent with small bowel obstruction. Laparoscopic-assisted exploration of the abdomen was offered, and a hard obstructing charcoal mass was found in the small bowel. Clinicians should be aware of the rare occurrence of gastrointestinal complication or obstruction following the administration of multiple-dose activated charcoal, especially in patients who ingested a drug that is potentially antiperistaltic.

A Synthetic Receptor as a Specific Antidote for Paraquat Poisoning

Accidental or suicidal ingestion of the world's most widely used herbicide, paraquat (PQ), may result in rapid multi-organ failure with a 60% fatality rate due to the absence of an effective detoxification solution. Effective, specific antidotes to PQ poisoning have been highly desired.

Methods: The binding constant of PQ and a synthetic receptor, cucurbit[7]uril (CB[7]), was first determined in various pH environments. The antidotal effects of CB[7] on PQ toxicity were firstly evaluated with in-vitro cell lines. With in-vivo mice models, the pharmacokinetics and the biodistribution of PQ in major organs were determined to evaluate the influence of CB[7] on the oral bioavailability of PQ. Major organs' injuries and overall survival rates of the mice were systemically examined to evaluate the therapeutic efficacy of CB[7] on PQ poisoning.

Results: We demonstrate that CB[7] may complex PQ strongly under various conditions and significantly reduce its toxicity in vitro and in vivo. Oral administration of PQ in the presence of CB[7] in a mouse model significantly decreased PQ levels in the plasma and major organs and alleviated major organs' injuries, when compared to those of mice administered with PQ alone. Further studies indicated that oral administration of CB[7] within 2 h post PQ ingestion significantly increased the survival rates and extended the survival time of the mice, in contrast to the ineffective treatment by activated charcoal, which is commonly recommended for PQ decontamination.

Conclusion: CB[7] may be used as a specific oral antidote for PQ poisoning by strongly binding with PQ and inhibiting its absorption in the gastrointestinal tracts.

First aid interventions by laypeople for acute oral poisoning

BACKGROUND

Oral poisoning is a major cause of mortality and disability worldwide, with estimates of over 100,000 deaths due to unintentional poisoning each year and an overrepresentation of children below five years of age. Any effective intervention that laypeople can apply to limit or delay uptake or to evacuate, dilute or neutralize the poison before professional help arrives may limit toxicity and save lives.

OBJECTIVES

To assess the effects of pre-hospital interventions (alone or in combination) for treating acute oral poisoning, available to and feasible for laypeople before the arrival of professional help.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, ISI Web of Science, International Pharmaceutical Abstracts, and three clinical trials registries to 11 May 2017, and we also carried out reference checking and citation searching.

SELECTION CRITERIA

We included randomized controlled trials comparing interventions (alone or in combination) that are feasible in a pre-hospital setting for treating acute oral poisoning patients, including but potentially not limited to activated charcoal (AC), emetics, cathartics, diluents, neutralizing agents and body positioning.

DATA COLLECTION AND ANALYSIS

Two reviewers independently performed study selection, data collection and assessment. Primary outcomes of this review were incidence of mortality and adverse events, plus incidence and severity of symptoms of poisoning. Secondary outcomes were duration of symptoms of poisoning, drug absorption, and incidence of hospitalization and ICU admission.

MAIN RESULTS

We included 24 trials involving 7099 participants. Using the Cochrane 'Risk of bias' tool, we assessed no study as being at low risk of bias for all domains. Many studies were poorly reported, so the risk of selection and detection biases were often unclear. Most studies reported important outcomes incompletely, and we judged them to be at high risk of reporting bias.All but one study enrolled oral poisoning patients in an emergency department; the remaining study was conducted in a pre-hospital setting. Fourteen studies included multiple toxic syndromes or did not specify, while the other studies specifically investigated paracetamol (2 studies), carbamazepine (2 studies), tricyclic antidepressant (2 studies), yellow oleander (2 studies), benzodiazepine (1 study), or toxic berry intoxication (1 study). Eighteen trials investigated the effects of activated charcoal (AC), administered as a single dose (SDAC) or in multiple doses (MDAC), alone or in combination with other first aid interventions (a cathartic) and/or hospital treatments. Six studies investigated syrup of ipecac plus other first aid interventions (SDAC + cathartic) versus ipecac alone. The collected evidence was mostly of low to very low certainty, often downgraded for indirectness, risk of bias or imprecision due to low numbers of events.First aid interventions that limit or delay the absorption of the poison in the bodyWe are uncertain about the effect of SDAC compared to no intervention on the incidence of adverse events in general (zero events in both treatment groups; 1 study, 451 participants) or vomiting specifically (Peto odds ratio (OR) 4.17, 95% confidence interval (CI) 0.30 to 57.26, 1 study, 25 participants), ICU admission (Peto OR 7.77, 95% CI 0.15 to 391.93, 1 study, 451 participants) and clinical deterioration (zero events in both treatment groups; 1 study, 451 participants) in participants with mixed types or paracetamol poisoning, as all evidence for these outcomes was of very low certainty. No studies assessed SDAC for mortality, duration of symptoms, drug absorption or hospitalization.Only one study compared SDAC to syrup of ipecac in participants with mixed types of poisoning, providing very low-certainty evidence. Therefore we are uncertain about the effects on Glasgow Coma Scale scores (mean difference (MD) -0.15, 95% CI -0.43 to 0.13, 1 study, 34 participants) or incidence of adverse events (risk ratio (RR) 1.24, 95% CI 0.26 to 5.83, 1 study, 34 participants). No information was available concerning mortality, duration of symptoms, drug absorption, hospitalization or ICU admission.This review also considered the added value of SDAC or MDAC to hospital interventions, which mostly included gastric lavage. No included studies investigated the use of body positioning in oral poisoning patients.First aid interventions that evacuate the poison from the gastrointestinal tractWe found one study comparing ipecac versus no intervention in toxic berry ingestion in a pre-hospital setting. Low-certainty evidence suggests there may be an increase in the incidence of adverse events, but the study did not report incidence of mortality, incidence or duration of symptoms of poisoning, drug absorption, hospitalization or ICU admission (103 participants).In addition, we also considered the added value of syrup of ipecac to SDAC plus a cathartic and the added value of a cathartic to SDAC.No studies used cathartics as an individual intervention.First aid interventions that neutralize or dilute the poison No included studies investigated the neutralization or dilution of the poison in oral poisoning patients.The review also considered combinations of different first aid interventions.

AUTHORS' CONCLUSIONS

The studies included in this review provided mostly low- or very low-certainty evidence about the use of first aid interventions for acute oral poisoning. A key limitation was the fact that only one included study actually took place in a pre-hospital setting, which undermines our confidence in the applicability of these results to this setting. Thus, the amount of evidence collected was insufficient to draw any conclusions.

Self-poisoning with 60 tablets of Apixaban, a pharmacokinetics case report

A 67-year-old man was admitted to the emergency department about 5 h after deliberate self-poisoning with 300 mg of Apixaban. The clinical examination did not show any organ dysfunctions or haemorrhagic signs, and the patient's life was not in danger. The first analysis, upon admission, showed a concentration of 2655 μg l^-1 of Apixaban. The Cmax was observed 17 h after the intake (3654 μg l^-1 ), about four times the classical Tmax value (median [range]: 4 h [2-4]). The Apixaban was then eliminated following a first order elimination with a calculated half-life of 10.8 h. The anti-Xa activity seems to be linearly related to concentration up to 4000 μg l^-1 . This report suggests that the use of activated charcoal should be effective up to 17 h after a massive intake.