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Blundell M, Gill R, Thanacoody R, Humphries C, Wood DM, Dargan PI. Joint RCEM and NPIS best practice guideline: assessment and management of acute opioid toxicity in adults in the emergency department. Emerg Med J 2024:emermed-2024-214163. [PMID: 38763520 DOI: 10.1136/emermed-2024-214163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Accepted: 05/03/2024] [Indexed: 05/21/2024]
Abstract
The Royal College of Emergency Medicine Toxicology Special Interest Group in collaboration with the UK National Poisons Information Service and the Clinical Toxicology Department at Guy's and St Thomas' NHS Foundation Trust has produced guidance to support clinicians working in the ED with the assessment and management of adults with acute opioid toxicity.Considerations regarding identification of acute opioid toxicity are discussed and recommendations regarding treatment options and secondary prevention are made. There is a focus on making recommendations on the best available evidence.
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Affiliation(s)
- Matthew Blundell
- Emergency Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Rupinder Gill
- Emergency Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Ruben Thanacoody
- National Poisons Information Service (Newcastle), Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | - David M Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Paul I Dargan
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Faculty of Life Sciences and Medicine, King's College London, London, UK
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De Baerdemaeker K, Dines AM, Nefau T, Skapurova K, Giraudon I, Alachaher D, Archer JRH, Bentur Y, El Zahran T, Jovic-Stocic J, Omary A, Tahar AM, Thabet H, Thoma E, Vucinic S, Wood DM, Dargan PI. Comparison of recreational drug presentations to the emergency department in Europe, the Middle East and Northern Africa. Eur J Emerg Med 2024; 31:149-151. [PMID: 38416586 DOI: 10.1097/mej.0000000000001087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2024]
Affiliation(s)
- Klara De Baerdemaeker
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust
- Emergency Medicine, Guy's and St Thomas' NHS Foundation Trust, UK
| | - Alison M Dines
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust
| | - Thomas Nefau
- European Monitoring Centre for Drugs and Drug Addiction, Lisbon, Portugal
| | - Katerina Skapurova
- European Monitoring Centre for Drugs and Drug Addiction, Lisbon, Portugal
| | - Isabelle Giraudon
- European Monitoring Centre for Drugs and Drug Addiction, Lisbon, Portugal
| | - Djamel Alachaher
- Emergency Department, University Hospital of Oran, Oran, Algeria
| | - John R H Archer
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Yedidia Bentur
- The Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Tharwat El Zahran
- Emergency Department, American University of Beirut Medical Center, Beirut, Lebanon
| | | | - Asaad Omary
- The Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Ait Mouhab Tahar
- Emergency Department, Mohamed Liamine Debaghine Hospital, Bab El Oued University Hospital Center, Bab El Oued, Algeria
| | - Hafedh Thabet
- Emergency Department, Centre Mahmoud Yacoub d'assistance médicale urgente, Tunis, Tunisia
| | | | - Slavica Vucinic
- The National Poison Control Centre, Military Medical Academy, Belgrade, Serbia
| | - David M Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Paul I Dargan
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust
- Faculty of Life Sciences and Medicine, King's College London, London, UK
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Rubinic I, Kurtov M, Rubinic I, Likic R, Dargan PI, Wood DM. Artificial intelligence in clinical pharmacology: A case study and scoping review of large language models and bioweapon potential. Br J Clin Pharmacol 2024; 90:620-628. [PMID: 37658550 DOI: 10.1111/bcp.15899] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 08/23/2023] [Accepted: 08/24/2023] [Indexed: 09/03/2023] Open
Abstract
This paper aims to explore the possibility of employing large language models (LLMs) - a type of artificial intelligence (AI) - in clinical pharmacology, with a focus on its possible misuse in bioweapon development. Additionally, ethical considerations, legislation and potential risk reduction measures are analysed. The existing literature is reviewed to investigate the potential misuse of AI and LLMs in bioweapon creation. The search includes articles from PubMed, Scopus and Web of Science Core Collection that were identified using a specific protocol. To explore the regulatory landscape, the OECD.ai platform was used. The review highlights the dual-use vulnerability of AI and LLMs, with a focus on bioweapon development. Subsequently, a case study is used to illustrate the potential of AI manipulation resulting in harmful substance synthesis. Existing regulations inadequately address the ethical concerns tied to AI and LLMs. Mitigation measures are proposed, including technical solutions (explainable AI), establishing ethical guidelines through collaborative efforts, and implementing policy changes to create a comprehensive regulatory framework. The integration of AI and LLMs into clinical pharmacology presents invaluable opportunities, while also introducing significant ethical and safety considerations. Addressing the dual-use nature of AI requires robust regulations, as well as adopting a strategic approach grounded in technical solutions and ethical values following the principles of transparency, accountability and safety. Additionally, AI's potential role in developing countermeasures against novel hazardous substances is underscored. By adopting a proactive approach, the potential benefits of AI and LLMs can be fully harnessed while minimizing the associated risks.
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Affiliation(s)
- Igor Rubinic
- University of Rijeka School of Medicine, Rijeka, Croatia
- Clinical Hospital Centre Rijeka, Rijeka, Croatia
| | | | - Ivan Rubinic
- School of Engineering, University of Rijeka, Rijeka, Croatia
| | - Robert Likic
- University of Zagreb School of Medicine, Zagreb, Croatia
- Clinical Hospital Centre Zagreb, Zagreb, Croatia
| | - Paul I Dargan
- Faculty of Life Sciences and Medicine, King's College London, London, UK
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - David M Wood
- Faculty of Life Sciences and Medicine, King's College London, London, UK
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK
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Thurtle N, Kirby KA, Greig J, Bil K, Dargan PI, Ntadom GN, Buckley NA. Correction: Neonatal blood lead concentration predicts medium term lead-related outcomes in children ≤5 years old with congenital lead poisoning: A retrospective cohort study in Northern Nigeria. PLOS Glob Public Health 2024; 4:e0002912. [PMID: 38300919 PMCID: PMC10833547 DOI: 10.1371/journal.pgph.0002912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
[This corrects the article DOI: 10.1371/journal.pgph.0001644.].
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Sund LJ, Dargan PI, Archer JRH, Blundell MS, Wood DM. The Emerging Cloud: a survey of vapers, their health and utilization of healthcare within the UK. QJM 2023; 116:993-1001. [PMID: 37738584 PMCID: PMC10753409 DOI: 10.1093/qjmed/hcad210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 09/04/2023] [Indexed: 09/24/2023] Open
Abstract
BACKGROUND Recent work in the UK estimated the prevalence of current cannabinoid-based vaping to be higher than in the USA, a factor previously associated with e-cigarette or vaping-associated lung injury (EVALI). Research in the USA has demonstrated that attendances to emergency departments relating to e-cigarettes began to rise before the EVALI outbreak, suggesting that vapers also experience milder forms of vaping-related illness. AIM Quantify symptom prevalence and healthcare utilization amongst current UK vapers. DESIGN Voluntary online survey of individuals aged 16 and over within the UK. METHODS Anonymized data were collected on demographics, vaping/smoking status and vaping substances used. Current vapers were asked about the presence of 10 prevalent symptoms from previous US EVALI case series, healthcare attendances and diagnoses given. Risk-ratios were calculated to compare the likelihood of symptoms and attendances between substances. RESULTS A total of 2477 complete responses were analysed. In all, 397 respondents were current vapers. Symptom prevalence within the previous 12 months ranged from 3.8% to 30.5% (bloody sputum, cough). Healthcare attendances per symptomatic respondent ranged from 0.1 to 1.4 (bloody sputum, shortness of breath). Current vapers of cannabinoid-based products (alone/in combination) had the most attendances per symptomatic respondent for 9/10 symptoms and were more likely to report symptoms aside from 'cough' (nicotine-free e-liquids [risk ratio = 1.7]). Clinicians reportedly never diagnosed vaping-related illness. CONCLUSIONS UK vapers experience symptoms previously reported in EVALI cases for which they also seek healthcare. Users of cannabinoid-based products were more likely to report symptoms and accounted for a higher healthcare burden. UK vapers may also experience vaping-related illness that does not meet EVALI case criteria.
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Affiliation(s)
- L J Sund
- St Thomas' Hospital , Department of Emergency Medicine, Guy’s and St Thomas’ NHS Foundation Trust and King’s Health Partners, Westminster Bridge Rd, London SE1 7EH, UK
- St Thomas' Hospital , Department of Clinical Toxicology, Guy’s and St Thomas’ NHS Foundation Trust and King’s Health Partners, Westminster Bridge Rd, London SE1 7EH, UK
- St Thomas' Hospital campus , Faculty of Life Sciences and Medicine, King’s College London, Westminster Bridge Rd, London SE1 7EH, UK
| | - P I Dargan
- St Thomas' Hospital , Department of Clinical Toxicology, Guy’s and St Thomas’ NHS Foundation Trust and King’s Health Partners, Westminster Bridge Rd, London SE1 7EH, UK
- St Thomas' Hospital campus , Faculty of Life Sciences and Medicine, King’s College London, Westminster Bridge Rd, London SE1 7EH, UK
| | - J R H Archer
- St Thomas' Hospital , Department of Clinical Toxicology, Guy’s and St Thomas’ NHS Foundation Trust and King’s Health Partners, Westminster Bridge Rd, London SE1 7EH, UK
- St Thomas' Hospital campus , Faculty of Life Sciences and Medicine, King’s College London, Westminster Bridge Rd, London SE1 7EH, UK
| | - M S Blundell
- St Thomas' Hospital , Department of Emergency Medicine, Guy’s and St Thomas’ NHS Foundation Trust and King’s Health Partners, Westminster Bridge Rd, London SE1 7EH, UK
- St Thomas' Hospital , Department of Clinical Toxicology, Guy’s and St Thomas’ NHS Foundation Trust and King’s Health Partners, Westminster Bridge Rd, London SE1 7EH, UK
| | - D M Wood
- St Thomas' Hospital , Department of Clinical Toxicology, Guy’s and St Thomas’ NHS Foundation Trust and King’s Health Partners, Westminster Bridge Rd, London SE1 7EH, UK
- St Thomas' Hospital campus , Faculty of Life Sciences and Medicine, King’s College London, Westminster Bridge Rd, London SE1 7EH, UK
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Vallersnes OM, Dines AM, Wood DM, Heyerdahl F, Hovda KE, Yates C, Giraudon I, Caganova B, Ceschi A, Galicia M, Liakoni E, Liechti ME, Miró Ò, Noseda R, Persett PS, Põld K, Schmid Y, Scholz I, Vigorita F, Dargan PI. Self-discharge during treatment for acute recreational drug toxicity: an observational study from emergency departments in seven European countries. Int J Emerg Med 2023; 16:86. [PMID: 38030969 PMCID: PMC10685690 DOI: 10.1186/s12245-023-00566-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 11/22/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND Self-discharge is a risk factor for readmission and excess mortality. We assess the rate of self-discharge from the emergency department (ED) among presentations for acute recreational drug toxicity and identify factors associated with self-discharge. METHODS From the Euro-DEN Plus database of presentations to the ED with acute recreational drug toxicity, we extracted data from 11 centres in seven European countries from 2014 to 2017. Self-discharge was defined as taking one's own discharge or escaping from the ED before being medically cleared. We used multiple logistic regression analyses to look for factors associated with self-discharge. RESULTS Among 15,135 included presentations, 1807 (11.9%) self-discharged. Self-discharge rates varied from 1.7 to 17.1% between centres. Synthetic cannabinoids were associated with self-discharge, adjusted odds ratio 1.44 (95% confidence interval 1.10-1.89), as were heroin, 1.44 (1.26-1.64), agitation, 1.27 (1.10-1.46), and naloxone treatment, 1.27 (1.07-1.51), while sedation protected from self-discharge, 0.38 (0.30-0.48). CONCLUSION One in eight presentations self-discharged. There was a large variation in self-discharge rates across the participating centres, possibly partly reflecting different discharge procedures and practices. Measures to improve the management of agitation and cautious administration of naloxone to avoid opioid withdrawal symptoms may be approaches worth exploring to reduce self-discharge.
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Affiliation(s)
- Odd Martin Vallersnes
- Department of General Practice, University of Oslo, PB 1130, Blindern, Oslo, 0318, Norway.
- Oslo Accident and Emergency Outpatient Clinic, City of Oslo Health Agency, Oslo, Norway.
| | - Alison M Dines
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
| | - David M Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
- Clinical Toxicology, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Fridtjof Heyerdahl
- Prehospital Division, Oslo University Hospital, Oslo, Norway
- The Norwegian Air Ambulance Foundation, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Knut Erik Hovda
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Acute Medicine, Oslo University Hospital, Oslo, Norway
| | - Christopher Yates
- Emergency Department and Clinical Toxicology Unit, Hospital Universitari Son Espases, Palma, Spain
| | - Isabelle Giraudon
- European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal
| | - Blazena Caganova
- National Toxicological Information Centre, University Hospital, Bratislava, Slovakia
| | - Alessandro Ceschi
- Division of Clinical Pharmacology and Toxicology, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Miguel Galicia
- Emergency Department, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Evangelia Liakoni
- Clinical Pharmacology and Toxicology, Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Matthias E Liechti
- Clinical Pharmacology and Toxicology, University Hospital and University of Basel, Basel, Switzerland
| | - Òscar Miró
- Emergency Department, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Roberta Noseda
- Division of Clinical Pharmacology and Toxicology, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | | | - Kristiina Põld
- Emergeny Medicine Department, North-Estonia Medical Centre, Tallinn, Estonia
| | - Yasmin Schmid
- Clinical Pharmacology and Toxicology, University Hospital and University of Basel, Basel, Switzerland
| | - Irene Scholz
- Clinical Pharmacology and Toxicology, Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Paul I Dargan
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
- Clinical Toxicology, Faculty of Life Sciences and Medicine, King's College London, London, UK
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Ramasamy MN, Kelly EJ, Seegobin S, Dargan PI, Payne R, Libri V, Adam M, Aley PK, Martinez-Alier N, Church A, Jepson B, Khan M, Matthews S, Townsend GT, Vekemans J, Bibi S, Swanson PA, Lambe T, Pangalos MN, Villafana T, Pollard AJ, Green JA. Immunogenicity and safety of AZD2816, a beta (B.1.351) variant COVID-19 vaccine, and AZD1222 (ChAdOx1 nCoV-19) as third-dose boosters for previously vaccinated adults: a multicentre, randomised, partly double-blinded, phase 2/3 non-inferiority immunobridging study in the UK and Poland. Lancet Microbe 2023; 4:e863-e874. [PMID: 37783221 DOI: 10.1016/s2666-5247(23)00177-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 05/31/2023] [Accepted: 06/02/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND This study aimed to evaluate AZD2816, a variant-updated COVID-19 vaccine expressing the full-length SARS-CoV-2 beta (B.1.351) variant spike protein that is otherwise similar to AZD1222 (ChAdOx1 nCoV-19), and AZD1222 as third-dose boosters. METHODS This phase 2/3, partly double-blinded, randomised, active-controlled study was done at 19 sites in the UK and four in Poland. Adult participants who had received a two-dose AZD1222 or mRNA vaccine primary series were randomly assigned by means of an Interactive Response Technology-Randomisation and Trial Supply Management system (1:1 within each primary-series cohort, stratified by age, sex, and comorbidities) to receive AZD1222 or AZD2816 (intramuscular injection; 5 × 1010 viral particles). Participants, investigators, and all sponsor staff members involved in study conduct were masked to randomisation. AZD1222 and AZD2816 doses were prepared by unmasked study staff members. The primary objectives were to evaluate safety and humoral immunogenicity (non-inferiority of day-29 pseudovirus neutralising antibody geometric mean titre [GMT] against ancestral SARS-CoV-2: AZD1222 booster vs AZD1222 primary series [historical controls]; margin 0·67; SARS-CoV-2-seronegative participants). This study is registered with ClinicalTrials.gov, NCT04973449, and is completed. FINDINGS Between June 27 and Sept 30, 2021, 1394 participants of the 1741 screened were randomly assigned to AZD1222 or AZD2816 following an AZD1222 (n=373, n=377) or mRNA vaccine (n=322, n=322) primary series. In SARS-CoV-2-seronegative participants receiving AZD1222 or AZD2816, 78% and 80% (AZD1222 primary series) and 90% and 93%, respectively (mRNA vaccine primary series) reported solicited adverse events to the end of day 8; 2%, 2%, 1%, and 1% had serious adverse events and 12%, 12%, 10%, and 11% had adverse events of special interest, respectively, to the end of day 180. The primary immunogenicity non-inferiority endpoint was met: day-29 neutralising antibody GMT ratios (ancestral SARS-CoV-2) were 1·02 (95% CI 0·90-1·14) and 3·47 (3·09-3·89) with AZD1222 booster versus historical controls (AZD1222 and mRNA vaccine primary series, respectively). Responses against beta were greater with AZD2816 versus AZD1222 (GMT ratios, AZD1222, mRNA vaccine primary series 1·84 [1·63-2·08], 2·22 [1·99-2·47]). INTERPRETATION Both boosters were well tolerated, with immunogenicity against ancestral SARS-CoV-2 similar to AZD1222 primary-series vaccination. AZD2816 gave greater immune responses against beta versus AZD1222. FUNDING AstraZeneca.
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Affiliation(s)
- Maheshi N Ramasamy
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK; Oxford University Hospitals NHS Foundation Trust, Oxford, UK; National Institute for Health and Care Research, Oxford Biomedical Research Centre, Oxford, UK
| | - Elizabeth J Kelly
- Translational Medicine, Vaccines and Immune Therapies, BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, MD, USA
| | - Seth Seegobin
- Biometrics, Vaccines and Immune Therapies, BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK
| | - Paul I Dargan
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK; Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Ruth Payne
- Department of Infection, Immunity and Cardiovascular Disease, The Medical School, University of Sheffield, Sheffield, UK; Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Vincenzo Libri
- National Institute for Health and Care Research, University College London Hospitals, Clinical Research Facility, London, UK; National Institute for Health and Care Research, University College London Hospitals, Biomedical Research Centre, London, UK
| | - Matthew Adam
- Clinical Infection Research Group-Edinburgh, Regional Infectious Diseases Unit, NHS Lothian, Edinburgh, UK
| | - Parvinder K Aley
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK; National Institute for Health and Care Research, Oxford Biomedical Research Centre, Oxford, UK
| | - Nuria Martinez-Alier
- Formerly Paediatric Infectious Diseases and Immunology, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK; IQVIA, London, UK
| | - Alison Church
- Clinical Development, Vaccines and Immune Therapies, BioPharmaceuticals R&D, AstraZeneca, Durham, NC, USA
| | - Brett Jepson
- Biometrics, Vaccines and Immune Therapies, BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, MD, USA
| | - Mark Khan
- Clinical Development, BioPharmaceuticals R&D, AstraZeneca, Mississauga, ON, Canada
| | - Sam Matthews
- Biometrics, Vaccines and Immune Therapies, BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK
| | - G Todd Townsend
- Clinical Development, Vaccines and Immune Therapies, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Johan Vekemans
- Formerly Respiratory and Immunology, BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK
| | - Sagida Bibi
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK; National Institute for Health and Care Research, Oxford Biomedical Research Centre, Oxford, UK
| | - Phillip A Swanson
- Translational Medicine, Vaccines and Immune Therapies, BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, MD, USA
| | - Teresa Lambe
- Oxford Vaccine Group, Centre for Clinical Vaccinology and Tropical Medicine, Churchill Hospital, Oxford, UK; Chinese Academy of Medical Science Oxford Institute, University of Oxford, Oxford, UK
| | | | - Tonya Villafana
- Clinical Development, Vaccines and Immune Therapies, BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, MD, USA
| | - Andrew J Pollard
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK; National Institute for Health and Care Research, Oxford Biomedical Research Centre, Oxford, UK
| | - Justin A Green
- Clinical Development, Vaccines and Immune Therapies, BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK.
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Noseda R, Franchi M, Pagnamenta A, Müller L, Dines AM, Giraudon I, Heyerdahl F, Eyer F, Hovda KE, Liechti ME, Miró Ò, Vallersnes OM, Yates C, Dargan PI, Wood DM, Ceschi A. Determinants of Admission to Critical Care Following Acute Recreational Drug Toxicity: A Euro-DEN Plus Study. J Clin Med 2023; 12:5970. [PMID: 37762912 PMCID: PMC10532086 DOI: 10.3390/jcm12185970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 09/07/2023] [Accepted: 09/12/2023] [Indexed: 09/29/2023] Open
Abstract
This study aimed to characterize patients admitted to critical care following Emergency Department (ED) presentation with acute recreational drug toxicity and to identify determinants of admission to critical care. A retrospective multicenter matched case-control study was conducted by the European Drug Emergency Network Plus (Euro-DEN Plus) over the period 2014-2021. The cases were ED presentations with acute recreational drug toxicity admitted to critical care, the controls consisted of ED presentations with acute recreational drug toxicity medically discharged directly from the ED. The potential determinants of admission to critical care were assessed through multivariable conditional stepwise logistic regression analysis and multiple imputation was used to account for the missing data. From 2014 to 2021, 3448 Euro-DEN Plus presentations involved patients admitted to critical care (76.9% males; mean age 33.2 years; SD 10.9 years). Patient age ≥35 years (as compared to ≤18 years) was a determinant of admission to critical care following acute recreational drug toxicity (adjusted odds ratio, aOR, 1.51, 95% confidence interval, CI, 1.15-1.99), along with polydrug use (aOR 1.39, 95% CI 1.22-1.59), ethanol co-ingestion (aOR 1.44, 95% CI 1.26-1.64), and the use of gamma-hydroxybutyrate/gamma-butyrolactone (GHB/GBL, aOR 3.08, 95% CI 2.66-3.57). Conversely, lower odds of admission to critical care were associated with the use of cocaine (aOR 0.85, 95% CI 0.74-0.99), cannabis (aOR 0.44, 95% CI 0.37-0.52), heroin (aOR 0.80, 95% CI 0.69-0.93), and amphetamine (aOR 0.65, 95% CI 0.54-0.78), as was the arrival to the ED during the night (8 p.m.-8 a.m., aOR 0.88, 95% CI 0.79-0.98). These findings, which deserve confirmation and further investigation, could contribute to a more complete understanding of the decision-making process underlying the admission to critical care of patients with acute recreational drug toxicity.
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Affiliation(s)
- Roberta Noseda
- Division of Clinical Pharmacology and Toxicology, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, 6900 Lugano, Switzerland; (R.N.); (L.M.)
| | - Matteo Franchi
- Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, 20126 Milan, Italy;
- National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, 20126 Milan, Italy
| | - Alberto Pagnamenta
- Clinical Trial Unit, Ente Ospedaliero Cantonale, 6900 Lugano, Switzerland;
- Department of Intensive Care, Ente Ospedaliero Cantonale, 6900 Lugano, Switzerland
- Division of Pneumology, University of Geneva, 1211 Geneva, Switzerland
| | - Laura Müller
- Division of Clinical Pharmacology and Toxicology, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, 6900 Lugano, Switzerland; (R.N.); (L.M.)
| | - Alison M. Dines
- Clinical Toxicology, Guy’s and St Thomas’ NHS Foundation Trust and King’s Health Partners, London SE1 7EH, UK; (A.M.D.); (P.I.D.); (D.M.W.)
| | - Isabelle Giraudon
- European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), 1249-289 Lisbon, Portugal;
| | - Fridtjof Heyerdahl
- Prehospital Division, Oslo University Hospital, 0424 Oslo, Norway;
- The Norwegian Air Ambulance Foundation, 0184 Oslo, Norway
| | - Florian Eyer
- Department of Clinical Toxicology, Klinikum Rechts der Isar, Technical University of Munich, 81675 Munich, Germany;
| | - Knut Erik Hovda
- The Norwegian CBRNE Centre of Medicine, Oslo University Hospital, 0450 Oslo, Norway;
| | - Matthias E. Liechti
- Clinical Pharmacology and Toxicology, University Hospital and University of Basel, 4056 Basel, Switzerland;
| | - Òscar Miró
- Emergency Department, Hospital Clínic, University of Barcelona, 08036 Catalonia, Spain;
| | - Odd Martin Vallersnes
- Department of General Practice, University of Oslo, 0318 Oslo, Norway;
- Oslo Accident and Emergency Outpatient Clinic, City of Oslo Health Agency, 0182 Oslo, Norway
| | - Christopher Yates
- Emergency Department and Clinical Toxicology Unit, Hospital Universitario Son Espases, 07120 Mallorca, Spain;
| | - Paul I. Dargan
- Clinical Toxicology, Guy’s and St Thomas’ NHS Foundation Trust and King’s Health Partners, London SE1 7EH, UK; (A.M.D.); (P.I.D.); (D.M.W.)
- Clinical Toxicology, Faculty of Life Sciences and Medicine, King’s College London, London WC2R 2LS, UK
| | - David M. Wood
- Clinical Toxicology, Guy’s and St Thomas’ NHS Foundation Trust and King’s Health Partners, London SE1 7EH, UK; (A.M.D.); (P.I.D.); (D.M.W.)
- Clinical Toxicology, Faculty of Life Sciences and Medicine, King’s College London, London WC2R 2LS, UK
| | - Alessandro Ceschi
- Division of Clinical Pharmacology and Toxicology, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, 6900 Lugano, Switzerland; (R.N.); (L.M.)
- Clinical Trial Unit, Ente Ospedaliero Cantonale, 6900 Lugano, Switzerland;
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, 6900 Lugano, Switzerland
- Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, 8091 Zurich, Switzerland
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9
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Lee IT, Cosgrove CA, Moore P, Bethune C, Nally R, Bula M, Kalra PA, Clark R, Dargan PI, Boffito M, Sheridan R, Moran E, Darton TC, Burns F, Saralaya D, Duncan CJA, Lillie PJ, San Francisco Ramos A, Galiza EP, Heath PT, Girard B, Parker C, Rust D, Mehta S, de Windt E, Sutherland A, Tomassini JE, Dutko FJ, Chalkias S, Deng W, Chen X, Feng J, Tracy L, Zhou H, Miller JM, Das R. Omicron BA.1-containing mRNA-1273 boosters compared with the original COVID-19 vaccine in the UK: a randomised, observer-blind, active-controlled trial. Lancet Infect Dis 2023; 23:1007-1019. [PMID: 37348519 DOI: 10.1016/s1473-3099(23)00295-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 04/07/2023] [Accepted: 04/27/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND The omicron BA.1 bivalent booster is used globally. Previous open-label studies of the omicron BA.1 (Moderna mRNA-1273.214) booster showed superior neutralising antibody responses against omicron BA.1 and other variants compared with the original mRNA-1273 booster. We aimed to compare the safety and immunogenicity of omicron BA.1 monovalent and bivalent boosters with the original mRNA-1273 vaccine in a large, randomised controlled trial. METHODS In this large, randomised, observer-blind, active-controlled, phase 3 trial in the UK (28 hospital and vaccination clinic sites), individuals aged 16 years or older who had previously received two injections of any authorised or approved COVID-19 vaccine, with or without an mRNA vaccine booster (third dose), were randomly allocated (1:1) using interactive response technology to receive 50 μg omicron BA.1 monovalent or bivalent vaccines or 50 μg mRNA-1273 administered as boosters via deltoid intramuscular injection. The primary outcomes were safety and immunogenicity at day 29, including prespecified non-inferiority and superiority of booster immune responses, based on the neutralising antibody geometric mean concentration (GMC) ratios of the monovalent and bivalent boosters compared with mRNA-1273. Safety was assessed in all participants who received first or second boosters, and primary immunogenicity outcomes were assessed in all participants who received the planned booster dose, had pre-booster and day 29 antibody data, had no major protocol deviations, and who were SARS-CoV-2-negative. The study is registered with EudraCT (2022-000063-51) and ClinicalTrials.gov (NCT05249829) and is ongoing. FINDINGS Between Feb 16 and March 24, 2022, 724 participants were randomly allocated to receive omicron BA.1 monovalent (n=366) or mRNA-1273 (n=357), and between April 2 and June 17, 2022, 2824 participants were randomly allocated to receive omicron BA.1 bivalent (n=1418) or mRNA-1273 (n=1395) vaccines as second boosters. Median durations (months) between the most recent COVID-19 vaccine and study boosters were similar for omicron BA.1 monovalent (4·0 months [IQR 3·6-4·7]) and mRNA-1273 (4·1 [3·5-4·7]), and for the omicron BA.1 bivalent (5·5 [4·8-6·2]) and mRNA-1273 (5·4 [4·8-6·2]) boosters. The omicron BA.1 monovalent and bivalent boosters elicited superior neutralising GMCs against the omicron BA.1 variant compared with mRNA-1273, with GMC ratios of 1·68 (99% CI 1·45-1·95) and 1·53 (1·41-1·67) at day 29 post-booster doses in participants without previous SARS-CoV-2 infection. Both boosters induced non-inferior ancestral SARS-CoV-2 (Asp614Gly) immune responses with GMCs that were similar for the bivalent (2987·2 [95% CI 2814·9-3169·9]) versus mRNA-1273 (2911·3 [2750·9-3081·0]) and lower for the monovalent (2699·7 [2431·3-2997·7] vs 3020·6 [2776·5-3286·2]) boosters, with respective GMC ratios of 1·05 (99% CI 0·96-1·15) and 0·82 (95% CI 0·74-0·91). Results were comparable regardless of previous SARS-CoV-2 infection status. Incidences of solicited adverse reactions with the omicron BA.1 monovalent (335 [91·3%] of 367 participants) and omicron BA.1 bivalent (1285 [90·4%] of 1421 participants) boosters were similar to those observed previously for mRNA-1273, with no new safety concerns identified and no occurrences of fatal adverse events. INTERPRETATION Omicron-containing booster vaccines generated superior immunogenicity against omicron BA.1 and comparable immunogenicity against the original strain with no new safety concerns. It remains important to continuously monitor the immune responses and real-world vaccine effectiveness as divergent SARS-CoV-2 variants emerge. FUNDING Moderna.
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Affiliation(s)
| | - Catherine A Cosgrove
- Vaccine Institute, Centre for Neonatal and Paediatric Infection, St George's University of London, London, UK
| | - Patrick Moore
- Adam Practice, Poole, UK; University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | | | - Marcin Bula
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Philip A Kalra
- Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | | | - Paul I Dargan
- Guy's & St Thomas' NHS Foundation Trust, King's College London, London, UK
| | - Marta Boffito
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK; Department of Infectious Disease, Imperial College London, London, UK
| | | | | | - Thomas C Darton
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Fiona Burns
- Royal Free London NHS Foundation Trust University and University College London, London, UK
| | - Dinesh Saralaya
- National Institute for Health Research Patient Recruitment Centre, Bradford, UK; Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Christopher J A Duncan
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK; NIHR Newcastle Clinical Research Facility, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Patrick J Lillie
- Hull University Teaching Hospitals NHS Trust, Castle Hill Hospital, Cottingham, UK
| | - Alberto San Francisco Ramos
- Vaccine Institute, Centre for Neonatal and Paediatric Infection, St George's University of London, London, UK
| | - Eva P Galiza
- Vaccine Institute, Centre for Neonatal and Paediatric Infection, St George's University of London, London, UK
| | - Paul T Heath
- Vaccine Institute, Centre for Neonatal and Paediatric Infection, St George's University of London, London, UK
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Stolbach AI, Dargan PI, Greller HA, Hamilton RJ, Johnson-Arbor K, Murray BP, Ovakim D, Tormoehlen L, Nelson LS. ACMT Position Statement: End the Use of the Term "Excited Delirium". J Med Toxicol 2023:10.1007/s13181-023-00944-4. [PMID: 37349654 DOI: 10.1007/s13181-023-00944-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 04/26/2023] [Accepted: 04/28/2023] [Indexed: 06/24/2023] Open
Affiliation(s)
| | - Paul I Dargan
- Clinical Toxicology, Guy's and St, Thomas' NHS Foundation Trust, London, UK
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Howard A Greller
- Rutgers New Jersey Medical School - University Hospital, Newark, NJ, USA
- Department of Emergency Medicine, New Jersey Poison Information and Education System (NJPIES), Newark, NJ, USA
| | | | - Kelly Johnson-Arbor
- National Capital Poison Center, MedStar Georgetown University Hospital, Washington, DC, USA
| | | | - Daniel Ovakim
- Department of Medicine, British Columbia Drug and Poison Information Centre, University of British Columbia, Vancouver, BC, Canada
| | - Laura Tormoehlen
- Departments of Neurology and Emergency Medicine, Indiana University, Indianapolis, IN, USA
| | - Lewis S Nelson
- Rutgers New Jersey Medical School - University Hospital, Newark, NJ, USA
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Thurtle N, Kirby KA, Greig J, Bil K, Dargan PI, Ntadom GN, Buckley NA. Neonatal blood lead concentration predicts medium term lead-related outcomes in children ≤5 years old with congenital lead poisoning: A retrospective cohort study in Northern Nigeria. PLOS Glob Public Health 2023; 3:e0001644. [PMID: 36989232 PMCID: PMC10057808 DOI: 10.1371/journal.pgph.0001644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 01/17/2023] [Indexed: 03/30/2023]
Abstract
Mother-to-child-transmission of lead via the placenta is known to result in congenital lead toxicity. Between 2010 and 2021, Médecins Sans Frontières and other stakeholders responded to a severe lead poisoning outbreak related to artisanal gold mining in Northern Nigeria. Extensive environmental remediation occurred following outbreak identification; source control efforts are ongoing within the community. We aimed to describe the prevalence of congenital lead poisoning in this cohort and analyse the association between neonatal blood lead concentration (BLC) and medium-term lead-related outcomes during the study period. Children enrolled in the lead poisoning programme between July 2010 and 25 January 2018 who had a screening BLC at ≤4 weeks of age were included. For time-to-event analysis, medium-term outcomes were classified as lead-related (death from lead encephalopathy, and/or met chelation threshold) and non-lead-related (non-lead-related death, on programme no chelation, exit from programme without chelation). Cox regression analysis and ROC analysis were performed. 1468 children were included. All-cause mortality 2.3%; geometric mean neonatal BLC 13.7 μg/dL; 'lead-related death or treatment' 19.3%. For every doubling in neonatal BLC, there was an almost 8-fold increase in adjusted hazard ratio (HR) for the composite lead-related outcome (p<0.001). A neonatal BLC ≥ 15.0 μg/dL had 95% sensitivity for identifying children who went on to have the composite outcome (with specificity 67%; positive likelihood ratio 2.86). Congenital lead poisoning predicts ongoing exposure in this population, even after environmental remediation. This suggests a complex, early, multidisciplinary approach to source control and exposure management is required when elevated neonatal BLC is observed in lead poisoning clusters in low-and-middle-income contexts.
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Affiliation(s)
- Natalie Thurtle
- Médecins Sans Frontières, Operational Centre Amsterdam, Amsterdam, Holland
- Department of Pharmacology, University of Sydney, Sydney, NSW Australia
| | | | - Jane Greig
- Médecins Sans Frontières, Manson Unit, London, United Kingdom
| | - Karla Bil
- Médecins Sans Frontières, Operational Centre Amsterdam, Amsterdam, Holland
| | - Paul I. Dargan
- Clinical Toxicology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
- Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
| | - Godwin N. Ntadom
- Federal Ministry of Health, Abuja, Nigeria
- Nigerian Field Epidemiology and Laboratory Training Programme (NFELTP), Abuja, Nigeria
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12
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Sund LJ, Wood DM, Archer JRH, Blundell MS, Dargan PI. The unseen cloud: a survey of vaping practices and the acquisition of vaping products within the UK. QJM 2023; 116:99-106. [PMID: 36066433 DOI: 10.1093/qjmed/hcac220] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 08/25/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Vaping of cannabinoid-based products and informal acquisition of vaping products were associated with the outbreak of E-cigarette or vaping associated lung injury (EVALI) in the USA. Current prevalence of cannabinoid-based vaping within the UK is not known and literature regarding the acquisition of vaping products is limited. AIM To estimate the prevalence of nicotine-based, nicotine-free and cannabinoid-based product vaping within the UK and to determine where vaping products are acquired. DESIGN AND METHODS A voluntary online survey of individuals aged 16 and over within the UK was conducted using a convenience sample. Data were collected on respondent demographics, smoking/vaping history and acquisition of e-liquids/products. RESULTS A total of 2478 responses were included. Median age 45 years (interquartile range 35-57). Prevalence of current vaping of nicotine-based e-liquids, nicotine-free e-liquids and cannabinoid-based products was 14.4%, 11.2% and 5.49%, respectively. Current nicotine-based and nicotine-free vaping was most prevalent in 25-34 years olds (22.4% and 19.2% of respondents). Current cannabinoid-based vaping was most prevalent in 16-24 years olds. The most common 'ever' used cannabinoid-based products were cannabidiol oil/cannabigerol oil and cannabis leaves (4.8%). Specialist vaping stores were the most common source of 'ever' acquisition for all products. 36.8% and 40.5% of respondents who had ever vaped nicotine-based and nicotine-free e-liquids reported prior acquisition from informal sources. CONCLUSION This survey reported a higher prevalence of current cannabinoid-based vaping within the UK (5.5%) than previously reported in the USA (2.0%). In addition to the informal acquisition of vaping products as demonstrated within the survey, these results highlight potential underestimation of the risk of EVALI within the UK.
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Affiliation(s)
- L J Sund
- From the Emergency Medicine, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
| | - D M Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - J R H Archer
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - M S Blundell
- From the Emergency Medicine, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
| | - P I Dargan
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
- Faculty of Life Sciences and Medicine, King's College London, London, UK
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De Baerdemaeker KSC, Dines AM, Hudson S, Sund LJ, Waters ML, Hunter LJ, Blundell MS, Archer JRH, Wood DM, Dargan PI. Isotonitazene, a novel psychoactive substance opioid, detected in two cases following a local surge in opioid overdoses. QJM 2023; 116:115-119. [PMID: 35169852 DOI: 10.1093/qjmed/hcac039] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Isotonitazene is a novel opioid that was first reported in Europe in 2019. There have been no reports of the detection of isotonitazene in patients presenting to the emergency department with acute drug toxicity. AIM There was an increase in presentations to our emergency department with acute opioid toxicity in August 2021. We aim to describe this outbreak and provide detail on two cases in which isotonitazene was quantified in serum samples. METHODS Serum samples were available for comprehensive toxicological analysis for two presentations. Written consent was obtained and the samples were analysed through a Thermo XRS ultrahigh-performance liquid chromatography system, interfaced to a Thermo Q Exactive high-resolution accurate mass spectrometer, operating in heated positive ion electrospray mode. Acquired data were processed using Toxfinder software (Thermo) against a regularly updated in-house database. RESULTS There was an increase in acute opioid presentations to our emergency department from a median of 10 per month to 36 in August 2021. Twenty were treated with naloxone, and 23 were admitted to the hospital for observation and treatment. Serum sample analysis from two patients with acute opioid toxicity responsive to naloxone detected the presence of isotonitazene (0.18 and 0.81 ng/ml). CONCLUSION We report a cluster of acute opioid toxicity presentations to our Emergency Department with detection of isotonitazene in two cases. Analytical screening is important in determining the presence of novel psychoactive substances (NPS) and to help inform the public health of the implications of NPS use, particularly during clusters of acute recreational drug toxicity presentations.
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Affiliation(s)
- K S C De Baerdemaeker
- From the Clinical Toxicology, Guy's & St Thomas' NHS Foundation Trust, London, UK
- Emergency Medicine, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - A M Dines
- From the Clinical Toxicology, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - S Hudson
- Sport and Specialised Analytical Services, LGC Ltd, Fordham, UK
| | - L J Sund
- From the Clinical Toxicology, Guy's & St Thomas' NHS Foundation Trust, London, UK
- Emergency Medicine, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - M L Waters
- From the Clinical Toxicology, Guy's & St Thomas' NHS Foundation Trust, London, UK
- Emergency Medicine, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - L J Hunter
- From the Clinical Toxicology, Guy's & St Thomas' NHS Foundation Trust, London, UK
- Emergency Medicine, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - M S Blundell
- From the Clinical Toxicology, Guy's & St Thomas' NHS Foundation Trust, London, UK
- Emergency Medicine, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - J R H Archer
- From the Clinical Toxicology, Guy's & St Thomas' NHS Foundation Trust, London, UK
- Sport and Specialised Analytical Services, LGC Ltd, Fordham, UK
- General Medicine, Guy's & St Thomas' NHS Foundation Trust, London, UK
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - D M Wood
- From the Clinical Toxicology, Guy's & St Thomas' NHS Foundation Trust, London, UK
- Sport and Specialised Analytical Services, LGC Ltd, Fordham, UK
- General Medicine, Guy's & St Thomas' NHS Foundation Trust, London, UK
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - P I Dargan
- From the Clinical Toxicology, Guy's & St Thomas' NHS Foundation Trust, London, UK
- Sport and Specialised Analytical Services, LGC Ltd, Fordham, UK
- General Medicine, Guy's & St Thomas' NHS Foundation Trust, London, UK
- Faculty of Life Sciences and Medicine, King's College London, London, UK
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Sund LJ, Dargan PI, Archer JRH, Wood DM. E-cigarette or vaping-associated lung injury (EVALI): a review of international case reports from outside the United States of America. Clin Toxicol (Phila) 2023; 61:91-97. [PMID: 36636876 DOI: 10.1080/15563650.2022.2160342] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
INTRODUCTION E-cigarette or vaping-associated lung injury has been reported extensively throughout the United States without a corresponding number of international cases. Cannabinoid-based products have been implicated in the majority of cases. OBJECTIVES To collate published reports of E-cigarette or vaping-associated lung injury outside the United States and to identify the reasons behind the discrepancy in reported cases between the United States and the international community. METHODS PubMed and Healthcare Databases Advanced Search were used to identify published case reports of E-cigarette or vaping-associated lung injury prior to February 2021 using the search terms "e-cigarette", "e-cigarettes", "vaping", "vape" and, "lung injury", "pulmonary", "respiratory". Cases occurring in the United States were excluded. Non-United States case reports were excluded if they did not meet the Centers for Disease Control and Prevention "probable case" criteria. This requires use of a vaping device within 90 days of symptom onset, the presence of pulmonary infiltrates on plain film chest radiography or ground glass opacities on computerised tomography, clinical suspicion that infection was not the underlying cause of lung injury, and the absence of other plausible medical processes to account for the presentation. Patient demographics, nature of exposure, symptomatology and outcome were compared to 125 cases from three regional United States based case series, which were chosen on the basis of having complete data for these comparative factors. RESULTS Seventeen international cases from 13 countries were identified for analysis. There was a male predominance in both non-United States and United States cohorts (76% vs 58-83%), with a marginally higher median patient age in non-United States cases (31 vs 27, 19, 27 years). Reported use of nicotine/flavoured e-liquids was more common in non-United States cases (100% vs 58-67%), and use of cannabinoid-based products was less common (24% vs 78-92%). The most common symptoms across all cohorts were shortness of breath (76% vs 85-91%), cough (59% vs 78-83%) and fever (47% vs 78-83%). The majority of patients were hypoxic (76% vs 69-86%) and required hospital admission (88% vs 90-94%). Fewer of the non-United States patients required intensive care admission (24% vs 55-67%) though their median length of stay was longer (15 days vs 5, 6, 7 days). DISCUSSION Uniformity amongst non-United States cases in regards to nicotine based and/or flavoured e-liquid exposure may underestimate the role of these substances in e-cigarette or vaping-associated lung injury. This is consistent with prior United States based research demonstrating increased presentations to emergency departments prior to the recognised "outbreak" of e-cigarette or vaping-associated lung injury at a time of increased nicotine based e-liquid uptake. A longer length of hospital stay, lower rate of intensive care admission and a higher rate of bronchoscopy in the non-United States cohort could be indicative of clinician inexperience internationally. It is unclear why the non-United States cases also had a lower incidence of gastrointestinal symptoms however this may also be explained by poorer diagnostic awareness. CONCLUSIONS E-cigarette or vaping-associated lung injury is not limited to cannabinoid-based products. Apparent similarities in patient demographics, clinical features, and clinical course between non-United States and United States cases raise concern for underreporting of E-cigarette or vaping- associated lung injury internationally.
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Affiliation(s)
- Lachlan J Sund
- Emergency Medicine, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, United Kingdom of Great Britain and Northern Ireland
| | - Paul I Dargan
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, United Kingdom of Great Britain and Northern Ireland
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - John R H Archer
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, United Kingdom of Great Britain and Northern Ireland
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - David M Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, United Kingdom of Great Britain and Northern Ireland
- Faculty of Life Sciences and Medicine, King's College London, London, UK
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Virmani I, Oteo A, Dunn M, Vidler D, Roper C, Officer J, Hardy G, Dargan PI, Eddleston M, Cooper JG, Hill SL, Macfarlane R, Keating L, Haden M, Hudson S, Thomas SHL. Accuracy of substance exposure history in patients attending emergency departments after substance misuse; a comparison with biological sample analysis. Clin Toxicol (Phila) 2023; 61:39-46. [PMID: 36322622 DOI: 10.1080/15563650.2022.2131566] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
CONTEXT Acute toxicity caused by illicit substance use is a common reason for emergency department (ED) presentation. Knowledge of the substances involved is helpful for predicting and managing potential toxicity, but limited information is available about the accuracy of patient-reported substance exposure. This study assessed the accuracy of the history of exposure in those reporting use of a single substance by comparison with those identified by detailed toxicological analysis, focusing on synthetic cannabinoid receptor agonists (SCRA). METHODS Adults (≥16 years) presenting between March 2015 and July 2021 to participating UK hospitals with toxicity after reporting use of a single illicit substance were included. Exposure details were documented from medical records and blood and/or urine samples analysed using high-resolution accurate mass liquid chromatography-mass spectrometry (HRAM LCMS). Sensitivity, specificity, and positive and negative predictive values of the exposure history were calculated by comparison with biological sample analysis ("gold standard"). RESULTS Single substance exposure was reported for 474 (median age 33 years, IQR: 18 range 16-75, 80% males) patients. Analysis commonly identified multiple substances (Median 3, IQR 2-5). A history of exposure was documented for 121 of 151 patients where a SCRA or metabolite was detected on analysis (sensitivity 80.1%, 95% CI 72.9, 86.2%). Corresponding proportions were lower for 3,4-methylenedioxymethamphetamine (MDMA, 44/70, 62.9%., 95% CI 50.5%, 74.1%), heroin 41/108 (38.0% 95% CI 28.8-47.8%) and cocaine (22/56, 31.3%, 95% CI 20.9, 43.6%). CONCLUSIONS Multiple undeclared substances were detected analytically in most patients reporting single substance use. Clinicians should be alert to the potential presence and toxicity of unreported substances when managing patients presenting after substance misuse.
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Affiliation(s)
- Ishita Virmani
- Medical Toxicology Centre, Newcastle University, Newcastle, UK.,RECETOX, Faculty of Science, Masaryk University, Brno, Czech Republic
| | - Alberto Oteo
- Addictions and Inclusion Directorate, Department of Health and Social Care, Office for Health Improvement & Disparities, London, UK
| | - Michael Dunn
- Medical Toxicology Centre, Newcastle University, Newcastle, UK
| | - Daniel Vidler
- Medical Toxicology Centre, Newcastle University, Newcastle, UK
| | - Clair Roper
- Medical Toxicology Centre, Newcastle University, Newcastle, UK
| | - Jane Officer
- Scottish Police Authority Forensic Services, Edinburgh, UK
| | - Gareth Hardy
- Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - Paul I Dargan
- Clinical Toxicology, Guys & St Thomas' NHS Foundation Trust, London and Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Michael Eddleston
- Pharmacology, Toxicology & Therapeutics, University of Edinburgh, Edinburgh, UK
| | | | - Simon L Hill
- Medical Toxicology Centre, Newcastle University, Newcastle, UK.,Newcastle Hospitals NHS Foundation Trust and National Poisons Information Service, Newcastle, UK
| | | | - Liza Keating
- Royal Berkshire NHS Foundation Trust, Reading, UK
| | - Mark Haden
- St George's University Hospitals NHS Foundation Trust, London, UK
| | - Simon Hudson
- LGC Sport and Specialised Analytical Services, Fordham, UK
| | - Simon H L Thomas
- Medical Toxicology Centre, Newcastle University, Newcastle, UK.,Newcastle Hospitals NHS Foundation Trust and National Poisons Information Service, Newcastle, UK
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Crulli B, Dines AM, Blanco G, Giraudon I, Eyer F, Liechti ME, Miró Ò, Hovda KE, Heyerdahl F, Yates C, Vallersnes OM, Wood DM, Dargan PI. Novel psychoactive substances-related presentations to the emergency departments of the European drug emergencies network plus (Euro-DEN plus) over the six-year period 2014-2019. Clin Toxicol (Phila) 2022; 60:1318-1327. [PMID: 36322684 DOI: 10.1080/15563650.2022.2137524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Novel psychoactive substances (NPS) have been increasingly reported in the last 15-20 years. We aimed to describe presentations to the emergency department (ED) with acute recreational drug toxicity involving NPS. METHODS Data were extracted from the European Drug Emergencies Network (Euro-DEN) Plus database for all presentations to ED (36 EDs in 24 European countries) with acute toxicity between January 2014 and December 2019. Patient demographics, agents involved, and clinical outcomes were described and the subgroup of presentations involving NPS was compared with the rest of the cohort. RESULTS Out of 43,633 Euro-DEN Plus presentations, 3304 (7.6%) involved at least one NPS. Agents were identified mainly based on self-report or clinical presentation, with analytical confirmation being performed only in 17.9% of NPS presentations. The proportion of NPS presentations varied by centre (0-48.8%). For centres where data were available for all 6 years, NPS-related presentations peaked in 2015 (11.9%). In 2014, 78.4% of NPS agents reported were cathinones, while only 3.4% were synthetic cannabinoids (SCs); conversely, in 2019 only 11.6% of NPS agents reported were cathinones, while 72.2% were SCs. NPS-related presentations involved younger patients (median 30 (23-37) vs. 32 (25-40) years, p < 0.001) and more males (84.8 vs. 75.8%, p < 0.001) compared with the rest of the cohort. Patients presenting to ED after using NPS were more likely to self-discharge (22.8 vs. 15.1%), less likely to be admitted to critical care (3.6 vs. 6.1%) but had a longer length of stay in hospital (median 5.1 (2.7-18.7) vs. 4.7 (2.5-9.2) h, p < 0.001). Death occurred in 0.5% of all presentations involving NPS and in 0.4% of non-NPS presentations. CONCLUSIONS This large multicentre series of NPS presentations to European EDs showed marked geographical variation and changes over time in the proportion of presentations to ED involving NPS, as well as the proportion of NPS subgroups.
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Affiliation(s)
- Benjamin Crulli
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
| | - Alison M Dines
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
| | - Georgina Blanco
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
| | - Isabelle Giraudon
- European Monitoring Centre for Drugs and Drug Addiction, Lisbon, Portugal
| | - Florian Eyer
- Department of Clinical Toxicology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Matthias E Liechti
- Division of Clinical Pharmacology and Toxicology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Òscar Miró
- Emergency Department, Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Knut E Hovda
- Department of Acute Medicine, The National CBRNE Centre of Medicine, Medical Division, Oslo University Hospital, Oslo, Norway
| | - Fridtjof Heyerdahl
- Division of Prehospital Services, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Christopher Yates
- Emergency Department, Hospital Son Espases, Palma de Mallorca, Spain
| | - Odd Martin Vallersnes
- Department of General Practice, University of Oslo, Oslo, Norway.,Oslo Accident and Emergency Outpatient Clinic, City of Oslo Health Agency, Oslo, Norway
| | - David M Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Clinical Toxicology, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Paul I Dargan
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Clinical Toxicology, Faculty of Life Sciences and Medicine, King's College London, London, UK
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17
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Craft S, Dunn M, Vidler D, Officer J, Blagbrough IS, Pudney CR, Henderson G, Abouzeid A, Dargan PI, Eddleston M, Cooper J, Hill SL, Roper C, Freeman TP, Thomas SHL. Trends in hospital presentations following analytically confirmed synthetic cannabinoid receptor agonist exposure before and after implementation of the 2016 UK Psychoactive Substances Act. Addiction 2022; 117:2899-2906. [PMID: 35665553 PMCID: PMC9796520 DOI: 10.1111/add.15967] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 05/23/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND AIMS The United Kingdom (UK) Psychoactive Substances Act (PSA), implemented on the 26th May 2016, made the production, supply and sale of all non-exempted psychoactive substances illegal. The aim of this study was to measure trends in hospital presentations for severe toxicity following analytically confirmed synthetic cannabinoid receptor agonist (SCRA) exposure before and after implementation of the PSA. DESIGN Observational study. SETTING Thirty-four hospitals across the UK participating in the Identification of Novel Psychoactive Substances (IONA) study. PARTICIPANTS A total of 627 (79.9% male) consenting individuals who presented to participating hospitals between July 2015 and December 2019 with severe acute toxicity and suspected novel psychoactive substances exposure. MEASUREMENTS Toxicological analyses of patient samples were conducted using liquid-chromatography tandem mass-spectrometry. Time-series analysis was conducted on the monthly number of patients with and without analytically confirmed SCRA exposure using Poisson segmented regression. FINDINGS SCRAs were detected in 35.7% (n = 224) of patients. After adjusting for seasonality and the number of active sites, models showed no clear evidence of an upward or downward trend in the number of SCRA exposure cases in the period before (incidence rate ratio [IRR], 1.12; 95% CI, 0.99-1.26; P = 0.068) or after (IRR, 0.97; 95% CI, 0.94-1.01; P = 0.202) the implementation of the PSA. There was also no clear evidence of an upward or downward trend in non-SCRA exposure cases before (IRR, 1.12; 95% CI, 0.98-1.27; P = 0.105) or after (IRR, 1.01; 95% CI, 0.98-1.04; P = 0.478) implementation of the PSA. CONCLUSIONS There is no clear evidence of an upward or downward trend in the number of patients presenting to UK hospitals with severe acute toxicity following analytically confirmed synthetic cannabinoid receptor agonist exposure since the implementation of the Psychoactive Substances Act.
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Affiliation(s)
- Sam Craft
- Addiction and Mental Health Group (AIM), Department of PsychologyUniversity of BathBathUK
| | - Michael Dunn
- Translational and Clinical Research InstituteNewcastle UniversityNewcastleUK
| | - Dan Vidler
- Translational and Clinical Research InstituteNewcastle UniversityNewcastleUK
| | - Jane Officer
- Scottish Police Authority Forensic ServicesEdinburghUK
| | | | | | - Graeme Henderson
- School of Physiology, Pharmacology and NeuroscienceUniversity of BristolBristolUK
| | - Ahmed Abouzeid
- Blackpool Teaching Hospitals NHS Foundation TrustBlackpoolBlackpoolUK
| | | | | | | | - Simon L. Hill
- Newcastle Hospitals NHS Foundation Trust, Royal Victoria InfirmaryNewcastleUK
| | - Clair Roper
- Translational and Clinical Research InstituteNewcastle UniversityNewcastleUK
| | - Tom P. Freeman
- Addiction and Mental Health Group (AIM), Department of PsychologyUniversity of BathBathUK
| | - Simon H. L. Thomas
- Translational and Clinical Research InstituteNewcastle UniversityNewcastleUK
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18
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Janssens LK, Hudson S, Wood DM, Wolfe C, Dargan PI, Stove CP. Towards better understanding SCRAs and metabolites in recreational drug intoxications associated with 5F-MDMB-PICA use. Toxicologie Analytique et Clinique 2022. [DOI: 10.1016/j.toxac.2022.06.200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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19
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Janssens LK, Boeckaerts D, Hudson S, Morozova D, Cannaert A, Wood DM, Wolfe C, De Baets B, Stock M, Dargan PI, Stove CP. Large-scale activity-based SCRA screening on patient serum samples: CB1 bioassay supported by machine learning. Toxicologie Analytique et Clinique 2022. [DOI: 10.1016/j.toxac.2022.06.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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20
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Janssens LK, Hudson S, Wood DM, Wolfe C, Dargan PI, Stove CP. Linking in vitro and ex vivo CB 1 activity with serum concentrations and clinical features in 5F-MDMB-PICA users to better understand SCRAs and their metabolites. Arch Toxicol 2022; 96:2935-2945. [PMID: 35962200 DOI: 10.1007/s00204-022-03355-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 08/02/2022] [Indexed: 11/28/2022]
Abstract
Synthetic cannabinoid receptor agonists (SCRAs) pose a danger to public health. This study focused on individuals experiencing recreational drug toxicity who had used 5F-MDMB-PICA.Patient records were evaluated regarding vital signs, Glasgow Coma Scale (GCS) and clinical features. Liquid chromatography coupled to high-resolution mass spectrometry (LC-HRMS) confirmed and quantified the presence of 5F-MDMB-PICA (and/or metabolites) as the only SCRA present in the serum of 71 patients. Cannabinoid activity was evaluated by a cannabinoid receptor (CB1) bioassay, to assess the relationship between serum concentrations and ex vivo human CB1 activation potential. Furthermore, a link with the clinical presentation was appraised.5F-MDMB-PICA and five metabolites were pharmacologically profiled in vitro, revealing theoretically possible contributions of two active in vivo metabolites to overall cannabinoid activity. Serum concentrations of 5F-MDMB-PICA were correlated to the ex vivo cannabinoid activity, revealing a sigmoidal relationship. The latter could also be predicted based on pharmacological characterization of 5F-MDMB-PICA and its metabolites and an in-depth investigation of the bioassay outcome. Clinically, the GCS showed a significant trend (decrease) with increasing ex vivo cannabinoid activity.This is the first study to evaluate possible toxic effects of 5F-MDMB-PICA in a unique large patient cohort. It allows a better understanding of 5F-MDMB-PICA and metabolites in humans, suggesting a negligible contribution by 5F-MDMB-PICA metabolites to the overall cannabinoid activity in serum. Additionally, this work shows that in vitro pharmacological characterization allows close prediction of an individual's ex vivo CB1 activity, the latter showing a relationship with the level of consciousness.
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Affiliation(s)
- Liesl K Janssens
- Laboratory of Toxicology, Department of Bioanalysis, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Simon Hudson
- LGC Ltd- Sport and Specialised Analytical Services, Cambridge, UK
| | - David M Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Caitlin Wolfe
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Department of Emergency Medicine, Dalhousie University, Halifax, Canada
| | - Paul I Dargan
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Christophe P Stove
- Laboratory of Toxicology, Department of Bioanalysis, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium.
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21
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Etemadi A, Hariri S, Hassanian-Moghaddam H, Poustchi H, Roshandel G, Shayanrad A, Kamangar F, Boffetta P, Brennan P, Dargan PI, Dawsey SM, Jones RL, Freedman ND, Malekzadeh R, Abnet CC. Lead poisoning among asymptomatic individuals with a long-term history of opiate use in Golestan Cohort Study. Int J Drug Policy 2022; 104:103695. [PMID: 35472727 PMCID: PMC9133202 DOI: 10.1016/j.drugpo.2022.103695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 03/29/2022] [Accepted: 04/06/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Recent reports of lead poisoning suggest that people who use opium may be exposed to high amounts of lead. Here, we investigate the association between opium use and blood lead levels (BLL) in a population-based cohort study. METHODS In 2017, we studied a random sample of 410 people who currently (both within the past year and the past month) used opium and 104 who did not from participants of the Golestan Cohort Study in northeast Iran. Participants were stratified by sex and tobacco use history, completed a comprehensive opiate and tobacco use questionnaire and provided blood. BLL was measured by Lead Care® II Blood Lead Test Kit, validated by inductively coupled plasma triple quadrupole mass spectrometry. BLL was categorized as "<5 µg/dL", "elevated" (5-10 µg/dL), "high" (10-50 µg/dL), and "very high" (above 50 µg/dL). To assess the association between BLL categories and opiate use, route of consumption and weekly use, we used ordered logistic regression models, and report OR (odds ratio) and 95% CI (confidence interval) adjusted for age, sex, place of residence, education, occupation, household fuel type, and tobacco use. RESULTS In the cohort, participants used only raw (teriak) or refined (shireh) opium, which were smoked (45%, n = 184), taken orally (46%, n = 189), or both (9%, n = 37), for a mean duration of 24.2 (standard deviation: 11.6) years. The median BLL was significantly higher in people who currently used opium (11.4 µg/dL; IQR: 5.2-23.4) compared with those who did not (2.3 µg/dL; IQR: 2.3-4.2), and the highest median BLL was seen in oral use (21.7 µg/dL; IQR: 12.1-34.1). The BLL was <5 µg/dL among 79.8% of people with no opiate use, compared with only 22.7% in those using opium. BLL was elevated in 21.7%, high in 50.5% and very high in 5.1% of people using opium. About 95% of those with oral (180/189) or dual use (35/37) and 55% (102/184) of those who smoked opium had levels of blood lead above 5 µg/dL. The OR for the association between any opium use and each unit of increase in BLL category was 10.5 (95%CI: 5.8-19.1), and oral use of opium was a very strong predictor of increasing BLL category (OR=74.1; 95%CI: 35.1-156.3). This odds ratio was 38.8 (95%CI: 15.9-95.1) for dual use and 4.9 (95%CI: 2.6-9.1) for opium smoking. There was an independent dose-response association between average weekly dose and BLL among people using opium, overall and when stratified by route of use. CONCLUSION Our results indicate that regular use of lead-adulterated opium can expose individuals to high levels of lead, which may contribute to mortality and cancer risks associated with long-term opium use.
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Affiliation(s)
- Arash Etemadi
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, Bethesda, MD, USA.
| | - Sanam Hariri
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Liver and Pancreaticobilliary Research Center, Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Hossein Hassanian-Moghaddam
- Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Department of Clinical Toxicology, Loghman Hakim Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Hossein Poustchi
- Liver and Pancreaticobilliary Research Center, Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran; Digestive Oncology Research Center, Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Gholamreza Roshandel
- Golestan Research Center of Gastroenterology and Hepatology, Golestan University of Medical Sciences, Gorgan, Iran
| | - Amaneh Shayanrad
- Digestive Oncology Research Center, Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Farin Kamangar
- Department of Biology, School of Computer, Mathematical, and Natural Sciences, Morgan State University, Baltimore, MD, USA
| | - Paolo Boffetta
- Stony Brook Cancer Center, Stony Brook University, Stony Brook, New York, USA; Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy; Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Paul Brennan
- International Agency for Research on Cancer, Lyon, France
| | - Paul I Dargan
- Department of Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Sanford M Dawsey
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, Bethesda, MD, USA
| | - Robert L Jones
- National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Neal D Freedman
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, Bethesda, MD, USA
| | - Reza Malekzadeh
- Digestive Oncology Research Center, Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran.
| | - Christian C Abnet
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, Bethesda, MD, USA
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22
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Castelpietra G, Knudsen AKS, Agardh EE, Armocida B, Beghi M, Iburg KM, Logroscino G, Ma R, Starace F, Steel N, Addolorato G, Andrei CL, Andrei T, Ayuso-Mateos JL, Banach M, Bärnighausen TW, Barone-Adesi F, Bhagavathula AS, Carvalho F, Carvalho M, Chandan JS, Chattu VK, Couto RA, Cruz-Martins N, Dargan PI, Deuba K, da Silva DD, Fagbamigbe AF, Fernandes E, Ferrara P, Fischer F, Gaal PA, Gialluisi A, Haagsma JA, Haro JM, Hasan MT, Hasan SS, Hostiuc S, Iacoviello L, Iavicoli I, Jamshidi E, Jonas JB, Joo T, Jozwiak JJ, Katikireddi SV, Kauppila JH, Khan MA, Kisa A, Kisa S, Kivimäki M, Koly KN, Koyanagi A, Kumar M, Lallukka T, Langguth B, Ledda C, Lee PH, Lega I, Linehan C, Loureiro JA, Madureira-Carvalho ÁM, Martinez-Raga J, Mathur MR, McGrath JJ, Mechili EA, Mentis AFA, Mestrovic T, Miazgowski B, Mirica A, Mirijello A, Moazen B, Mohammed S, Mulita F, Nagel G, Negoi I, Negoi RI, Nwatah VE, Padron-Monedero A, Panda-Jonas S, Pardhan S, Pasovic M, Patel J, Petcu IR, Pinheiro M, Pollok RCG, Postma MJ, Rawaf DL, Rawaf S, Romero-Rodríguez E, Ronfani L, Sagoe D, Sanmarchi F, Schaub MP, Sharew NT, Shiri R, Shokraneh F, Sigfusdottir ID, Silva JP, Silva R, Socea B, Szócska M, Tabarés-Seisdedos R, Torrado M, Tovani-Palone MR, Vasankari TJ, Veroux M, Viner RM, Werdecker A, Winkler AS, Hay SI, Ferrari AJ, Naghavi M, Allebeck P, Monasta L. The burden of mental disorders, substance use disorders and self-harm among young people in Europe, 1990-2019: Findings from the Global Burden of Disease Study 2019. Lancet Reg Health Eur 2022; 16:100341. [PMID: 35392452 PMCID: PMC8980870 DOI: 10.1016/j.lanepe.2022.100341] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background Mental health is a public health issue for European young people, with great heterogeneity in resource allocation. Representative population-based studies are needed. The Global Burden of Disease (GBD) Study 2019 provides internationally comparable information on trends in the health status of populations and changes in the leading causes of disease burden over time. Methods Prevalence, incidence, Years Lived with Disability (YLDs) and Years of Life Lost (YLLs) from mental disorders (MDs), substance use disorders (SUDs) and self-harm were estimated for young people aged 10-24 years in 31 European countries. Rates per 100,000 population, percentage changes in 1990-2019, 95% Uncertainty Intervals (UIs), and correlations with Sociodemographic Index (SDI), were estimated. Findings In 2019, rates per 100,000 population were 16,983 (95% UI 12,823 - 21,630) for MDs, 3,891 (3,020 - 4,905) for SUDs, and 89·1 (63·8 - 123·1) for self-harm. In terms of disability, anxiety contributed to 647·3 (432-912·3) YLDs, while in terms of premature death, self-harm contributed to 319·6 (248·9-412·8) YLLs, per 100,000 population. Over the 30 years studied, YLDs increased in eating disorders (14·9%;9·4-20·1) and drug use disorders (16·9%;8·9-26·3), and decreased in idiopathic developmental intellectual disability (-29·1%;23·8-38·5). YLLs decreased in self-harm (-27·9%;38·3-18·7). Variations were found by sex, age-group and country. The burden of SUDs and self-harm was higher in countries with lower SDI, MDs were associated with SUDs. Interpretation Mental health conditions represent an important burden among young people living in Europe. National policies should strengthen mental health, with a specific focus on young people. Funding The Bill and Melinda Gates Foundation.
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Affiliation(s)
- Giulio Castelpietra
- Outpatient and Inpatient Care Service, Central Health Directorate, Region Friuli Venezia Giulia, Italy
| | | | - Emilie E. Agardh
- Department of Global Public Health, Karolinska Institute, Stockholm, Sweden
| | - Benedetta Armocida
- Department of Cardiovascular, Endocrine-metabolic Diseases and Aging, National Institute of Health, Rome, Italy
| | | | | | - Giancarlo Logroscino
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari Aldo Moro, Bari, Italy
- Department of Clinical Research in Neurology, Fondazione Cardinale Giovanni Panico Hospital, Tricase, Italy
| | - Rui Ma
- Institute for Health Metrics and Evaluation, Department of Health Metrics Sciences, University of Washington, Seattle, WA, USA
| | - Fabrizio Starace
- Department of Mental Health & Drug Abuse, AUSL Modena, Modena, Italy
| | - Nicholas Steel
- Department of Primary Care and Public Health, University of East Anglia, Norwich, UK
- Public Health England, London, UK
| | | | | | - Tudorel Andrei
- Department of Statistics and Econometrics Bucharest Carol Davila University of Economic Studies, Bucharest, Romania
| | - Jose L Ayuso-Mateos
- CIBERSAM, Institute of Health Carlos III, Madrid, Spain
- Department of Psychiatry, Universidad Autónoma de Madrid (Autonomous University of Madrid), Madrid, Spain
| | - Maciej Banach
- Department of Hypertension, Medical University of Lodz, Lodz, Poland
- Polish Mothers' Memorial Hospital Research Institute, Lodz, Poland
| | - Till Winfried Bärnighausen
- Heidelberg Institute of Global Health (HIGH), Heidelberg University, Heidelberg, Germany
- T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | | | - Akshaya Srikanth Bhagavathula
- Department of Social and Clinical Pharmacy, Charles University, Hradec Kralova, Czech Republic
- Institute of Public Health, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Felix Carvalho
- Research Unit on Applied Molecular Biosciences (UCIBIO), University of Porto, Porto, Portugal
| | - Márcia Carvalho
- Research Unit on Applied Molecular Biosciences (UCIBIO), University of Porto, Porto, Portugal
- Faculty of Health Sciences, University Fernando Pessoa, Porto, Portugal
| | - Joht Singh Chandan
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Vijay Kumar Chattu
- Faculty of Medical Sciences, University of the West Indies, St Augustine, Trinidad and Tobago
- Independent Consultant, Athens, Greece
| | - Rosa A.S. Couto
- Department of Chemical Sciences, University of Porto, Porto, Portugal
| | - Natália Cruz-Martins
- Department of Medicine (Prof N Cruz-Martins PhD), University of Porto, Porto, Portugal
- Department of Health Sciences Institute of Research and Advanced Training in Health Sciences and Technologies (CESPU), Famalicão, Portugal
| | - Paul I. Dargan
- Faculty of Life Sciences and Medicine, King's College London, London, UK
- Department of Clinical Toxicology, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Keshab Deuba
- National Centre for AIDS and STD Control, Save the Children, Kathmandu, Nepal
- Department of Global Public Health, Karolinska Institute, Stockholm, Sweden
| | | | - Adeniyi Francis Fagbamigbe
- Epidemiology and Medical Statistics, University of Ibadan, Ibadan, Nigeria
- Population and Behavioural Sciences, University of St Andrews, St Andrews, UK
| | - Eduarda Fernandes
- Associated Laboratory for Green Chemistry (LAQV), University of Porto, Porto, Portugal
| | - Pietro Ferrara
- Research Center on Public Health, University of Milan Bicocca, Monza, Italy
| | - Florian Fischer
- Institute of Public Health, Charité Universitätsmedizin Berlin (Charité Medical University Berlin), Berlin, Germany
| | - Peter Andras Gaal
- Health Services Management Training Centre, Semmelweis University, Budapest, Hungary
- Department of Applied Social Sciences, Sapientia Hungarian University of Transylvania, Târgu-Mureş, Romania
| | | | - Juanita A. Haagsma
- Department of Public Health, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Josep Maria Haro
- Research Unit, University of Barcelona, Barcelona, Spain
- Biomedical Research Networking Center for Mental Health Network (CiberSAM), Barcelona, Spain
| | - M. Tasdik Hasan
- Department of Pharmacy, University of Huddersfield, Huddersfield, UK
- School of Biomedical Sciences and Pharmacy, University of Newcastle, Newcastle, NSW, Australia
| | - Syed Shahzad Hasan
- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, UK
| | - Sorin Hostiuc
- Department of Legal Medicine and Bioethics, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Clinical Legal Medicine Department, National Institute of Legal Medicine Mina Minovici, Bucharest, Romania
| | - Licia Iacoviello
- Department of Epidemiology and Prevention, IRCCS Neuromed, Pozzilli, Italy
- Research Center in Epidemiology and Preventive Medicine (EPIMED), University of Insubria, Varese, Italy
| | - Ivo Iavicoli
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Elham Jamshidi
- Functional Neurosurgery Research Center, Shahid Beheshti University of Medical Sciences, Tehram, Iran
- Division of Pulmonary Medicine, University of Lausanne (UNIL), Lausanne, Switzerland
| | - Jost B. Jonas
- Institute of Molecular and Clinical Ophthalmology Basel, Basel, Switzerland
- Department of Ophthalmology, Heidelberg University, Mannheim, Germany
| | - Tamas Joo
- Health Services Management Training Centre, Semmelweis University, Budapest, Hungary
| | - Jacek Jerzy Jozwiak
- Department of Family Medicine and Public Health, University of Opole, Opole, Poland
| | | | - Joonas H. Kauppila
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
- Surgery Research Unit, University of Oulu, Oulu, Finland
| | - Moien A.B. Khan
- Family Medicine Department, United Arab Emirates University, Al Ain, United Arab Emirates
- Primary Care Department, NHS North West London, London, UK
| | - Adnan Kisa
- School of Health Sciences, Kristiania University College, Oslo, Norway
- Department of Global Community Health and Behavioral Sciences, Tulane University, New Orleans, LA, USA
| | - Sezer Kisa
- Department of Nursing and Health Promotion, Oslo Metropolitan University, Oslo, Norway
| | - Mika Kivimäki
- Department of Epidemiology and Public Health University College London, London, UK
- Department of Public Health, University of Helsinki, Helsinki, Finland
| | - Kamrun Nahar Koly
- Health System and Population Studies Divisions, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
- Center for Global Mental Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Ai Koyanagi
- Biomedical Research Networking Center for Mental Health Network (CIBERSAM), San Juan de Dios Sanitary Park, Sant Boi de Llobregat, Spain
- Catalan Institution for Research and Advanced Studies (ICREA), Barcelona, Spain
| | - Manasi Kumar
- Division of Psychology and Language Sciences, University College London, London, UK
- Department of Psychiatry, University of Nairobi, Nairobi, Kenya
| | - Tea Lallukka
- Department of Public Health, University of Helsinki, Helsinki, Finland
| | - Berthold Langguth
- Department of Psychiatry and Psychotherapy, University of Regensburg, Regensburg, Germany
| | - Caterina Ledda
- Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Paul H. Lee
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Ilaria Lega
- National Center for Disease Prevention and Health Promotion, Istituto Superiore di Sanità - Italian National Insitute of Health, Rome, Italy
| | - Christine Linehan
- UCD Centre for Disability Studies, University College Dublin, Dublin, Ireland
| | - Joana A. Loureiro
- Laboratory for Process Engineering, Environment, Biotechnology and Energy (LEPABE) University of Porto, Porto, Portugal
- School of Health, Polytechnic Institute of Porto, Portugal
| | - Áurea M Madureira-Carvalho
- Associated Laboratory for Green Chemistry (LAQV), University of Porto, Porto, Portugal
- Institute for Research and Advanced Training in Health Sciences and Technologies, Instituto Universitário de Ciências da Saúde (University Institute of Health Sciences), Gandra, Portugal
| | - Jose Martinez-Raga
- Psychiatry Department, Hospital Universitario Doctor Peset, Valencia, Spain
- Department of Medicine, University of Valencia, Valencia, Spain
| | - Manu Raj Mathur
- Health Policy Research Public Health Foundation of India, Gurugram, India
- Institute of Population Health Sciences, University of Liverpool, Liverpool, UK
| | - John J. McGrath
- Queensland Brain Institute, School of Public Health, The University of Queensland, Brisbane, QLD, Australia
- National Centre for Register-based Research, Aarhus University, Aarhus, Denmark
| | - Enkeleint A. Mechili
- Department of Healthcare, University of Vlora, Vlora city, Albania
- Clinic of Social and Family Medicine, University of Crete, Heraklion, Greece
| | | | - Tomislav Mestrovic
- Clinical Microbiology and Parasitology Unit, Dr. Zora Profozic Polyclinic, Zagreb, Croatia
- University Centre Varazdin, University North, Varazdin, Croatia
| | - Bartosz Miazgowski
- Center for Innovation in Medical Education, Pomeranian Medical University, Szczecin, Poland
| | - Andreea Mirica
- Department of Statistics and Econometrics Bucharest University of Economic Studies, Bucharest, Romania
| | - Antonio Mirijello
- Department of Medical Sciences IRCCS Casa Sollievo della Sofferenza General Hospital, San Giovanni Rotondo, Italy
| | - Babak Moazen
- Heidelberg Institute of Global Health (HIGH), Heidelberg University, Heidelberg, Germany
- Institute of Addiction Research (ISFF), Frankfurt University of Applied Sciences, Frankfurt, Germany
| | - Shafiu Mohammed
- Health Systems and Policy Research Unit, Ahmadu Bello University, Zaria, Nigeria
- Department of Health Care Management, Technical University of Berlin, Berlin, Germany
| | - Francesk Mulita
- Department of Surgery, General University Hospital of Patras, Patras, Greece
- Medical School, University of Thessaly, Larissa, Greece
| | - Gabriele Nagel
- Institute of Epidemiology and Medical Biometry Ulm University, Ulm, Germany
| | - Ionut Negoi
- Department of General Surgery Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Department of General Surgery, Emergency Hospital of Bucharest, Bucharest, Romania
| | - Ruxandra Irina Negoi
- Department of Anatomy and Embryology Romania, Bucharest, Romania
- Cardio-Aid, Bucharest, Romania
| | - Vincent Ebuka Nwatah
- Department of Pediatrics, National Hospital, Abuja, Nigeria
- Department of International Public Health, University of Liverpool, Liverpool, UK
| | | | | | - Shahina Pardhan
- Vision and Eye Research Institute, Anglia Ruskin University, Cambridge, UK
| | - Maja Pasovic
- Institute for Health Metrics and Evaluation, Department of Health Metrics Sciences, University of Washington, Seattle, WA, USA
| | - Jay Patel
- Global Health Governance Programme, University of Edinburgh, Edinburgh, UK
- School of Dentistry, University of Leeds, Leeds, UK
| | - Ionela-Roxana Petcu
- Department of Statistics and Econometrics Bucharest University of Economic Studies, Bucharest, Romania
| | - Marina Pinheiro
- Department of Chemistry, University of Porto, Porto, Portugal
| | | | - Maarten J. Postma
- University Medical Center Groningen, School of Economics and Business University of Groningen, Groningen, Netherlands
| | - David Laith Rawaf
- WHO Collaborating Centre for Public Health Education and Training Imperial College London, London, UK
| | - Salman Rawaf
- Department of Primary Care and Public Health, Imperial College London, London, UK
- University College London Hospitals, London, UK
- Academic Public Health England, London, UK
| | - Esperanza Romero-Rodríguez
- Clinical and Epidemiological Research in Primary Care (GICEAP), Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Cordoba, Spain
| | - Luca Ronfani
- Clinical Epidemiology and Public Health Research Unit, Burlo Garofolo Institute for Maternal and Child Health, Trieste, Italy
| | - Dominic Sagoe
- Department of Psychosocial Science University of Bergen, Bergen, Norway
| | - Francesco Sanmarchi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Michael P Schaub
- Swiss Research Institute for Public Health and Addiction University of Zürich, Zurich, Switzerland
| | - Nigussie Tadesse Sharew
- Interdisciplinary Centre Psychopathology and Emotion regulation (ICPE) University of Groningen, Groningen, Netherlands
- Department of Nursing, Debre Berhan University, Debre Berhan, Ethiopia
| | - Rahman Shiri
- Finnish Institute of Occupational Health, Helsinki, Finland
| | - Farhad Shokraneh
- London Institute for Healthcare Engineering, King's College London, London, UK
- Division of Psychiatry and Applied Psychology, University of Nottingham, Nottingham, UK
| | - Inga Dora Sigfusdottir
- Department of Psychology, Reykjavik University, Reykjavik, Iceland
- Department of Health and Behavior Studies, Columbia University, New York, NY, USA
| | - João Pedro Silva
- Research Unit on Applied Molecular Biosciences (UCIBIO), University of Porto, Porto, Portugal
| | - Renata Silva
- Department of Biological Sciences, University of Porto, Porto, Portugal
| | - Bogdan Socea
- Surgery, "Sf. Pantelimon" Emergency Clinical Hospital Bucharest, Bucharest, Romania
| | - Miklós Szócska
- Faculty of Health and Public Administration, Semmelweis University, Budapest, Hungary
| | - Rafael Tabarés-Seisdedos
- Department of Medicine, University of Valencia, Valencia, Spain
- Carlos III Health Institute, Biomedical Research Networking Center for Mental Health Network (CiberSAM), Madrid, Spain
| | - Marco Torrado
- Psychiatry and Medical Psychology Department, University of Lisbon, Lisbon, Portugal
- Child and Adolescent Mental Health Services (CAMHS), Hospital Garcia de Orta, Almada, Portugal
| | - Marcos Roberto Tovani-Palone
- Department of Pathology and Legal Medicine, University of São Paulo, Ribeirão Preto, Brazil
- Modestum LTD, London, UK
| | - Tommi Juhani Vasankari
- UKK Institute, Tampere, Finland
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Massimiliano Veroux
- Department of Medical and Surgical Sciences and Advanced Technologies, University of Catania, Catania, Italy
| | - Russell M. Viner
- UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Andrea Werdecker
- Demographic Change and Aging Research Area, Federal Institute for Population Research, Wiesbaden, Germany
| | - Andrea Sylvia Winkler
- Institute of Health and Society, University of Oslo, Oslo, Norway
- Department of Neurology, Technical University of Munich, Munich, Germany
| | - Simon I. Hay
- Institute for Health Metrics and Evaluation, Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Alize J. Ferrari
- Institute for Health Metrics and Evaluation, Department of Health Metrics Sciences, University of Washington, Seattle, WA, USA
- School of Public Health (A J Ferrari PhD), The University of Queensland, Brisbane, QLD, Australia
| | - Mohsen Naghavi
- Institute for Health Metrics and Evaluation, Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Peter Allebeck
- Department of Global Public Health, Karolinska Institute, Stockholm, Sweden
| | - Lorenzo Monasta
- Clinical Epidemiology and Public Health Research Unit, Burlo Garofolo Institute for Maternal and Child Health, Trieste, Italy
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Schmid Y, Galicia M, Vogt SB, Liechti ME, Burillo-Putze G, Dargan PI, Dines AM, Giraudon I, Heyerdahl F, Hovda KE, Wood DM, Yates C, Miró Ò. Differences in clinical features associated with cannabis intoxication in presentations to European emergency departments according to patient age and sex. Clin Toxicol (Phila) 2022; 60:912-919. [PMID: 35404194 DOI: 10.1080/15563650.2022.2060116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To investigate if clinical features associated with acute cannabis intoxication in patients presenting to Emergency Departments for medical assistance differ according to patient age and sex. METHODS We analysed presentations in the Euro-DEN Plus dataset from 2014 to 2019 in which cannabis was the only drug involved (except for alcohol), and age, sex and alcohol co-ingestion had been recorded. Age was considered as categorical (five groups; <20, 20-29, 30-39, 40-49 and ≥50 years), and sex as binary variable (male/female). We evaluated 12 key clinical features recorded during emergency department (ED) care. Risks of presenting with each of these clinical features according to patient age and sex were calculated by logistic regression models, and adjusted for sex, age and alcohol co-ingestion. RESULTS 4,268 of 43,633 Euro-DEN presentations (9.8%) fulfilled the inclusion criteria (median age: 26 years (IQR = 20-34), 70% male, 52% co-ingested alcohol). The frequency of clinical features was: anxiety 28%, vomiting 24%, agitation 23%, palpitations 14%, reduced consciousness 13%, acute psychosis 9%, hallucinations 9%, chest pain 7%, headache 6%, hypotension 4%, hypertension 3% and seizures 2%. Patients younger than 20 years more frequently had vomiting (34.7% of cases), reduced consciousness (21.5%), and headache (10.8%); and less frequently acute psychosis (5.5%). Patients older than 49 years more often had hypotension (6.5%) and less frequently vomiting (20%), anxiety (14%), agitation (14%) and reduced consciousness (10%). Males more frequently presented with hypertension (3.7 vs. 1.5%; OR = 2.311, 95%CI = 1.299-3.816), psychosis (10.4 vs 6.3%; 1.948, 1.432-2.430), chest pain (8.1 vs 4.5%; 1.838, 1.390-2.430) and seizures (2.5 vs 1.4%; 1.805, 1.065-3.060), and less frequently with vomiting (21.8 vs 28.2%; 0.793, 0.677-0.930), anxiety (25.4 vs 32.3%; 0.655, 0.561-0.766) and hypotension (2.9 vs 5.8%; 0.485, 0.350-0.671). CONCLUSIONS The prevalence of some clinical features typically associated with acute cannabis intoxication differed according to age and sex. The causes for these differences should be further investigated in order to better understand the pathophysiology of cannabis-related acute toxicity, and they may be relevant particularly for developing prevention campaigns and for treatment in specific sex and/or age groups.
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Affiliation(s)
- Yasmin Schmid
- Division of Clinical Pharmacology and Toxicology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Miguel Galicia
- Emergency Department, Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Catalonia, Spain
| | - Severin B Vogt
- Division of Clinical Pharmacology and Toxicology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Matthias E Liechti
- Division of Clinical Pharmacology and Toxicology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Guillermo Burillo-Putze
- Emergency Department, Hospital Universitario de Canarias, Universidad de La Laguna, Tenerife, Canary Islands, Spain
| | - Paul I Dargan
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Clinical Toxicology, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Alison M Dines
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
| | - Isabelle Giraudon
- European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal
| | - Fridtjof Heyerdahl
- Prehospital Division, Oslo University Hospital, Oslo, Norway.,The Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Knut Erik Hovda
- The Norwegian CBRNe Centre of Medicine, Oslo University Hospital, Oslo, Norway
| | - David M Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Clinical Toxicology, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Christopher Yates
- SAMU 061 Balears. Grupo de trabajo de Toxicología Clínica. IdISBa.Mallorca, Palma de Mallorca, Spain
| | - Òscar Miró
- Emergency Department, Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Catalonia, Spain
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24
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Fleming KM, Dargan PI, Massie J, Hodby K. Bicytopenia and neurological defects caused by zinc toxicity. Br J Haematol 2022; 198:e14-e17. [PMID: 35348202 DOI: 10.1111/bjh.18171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 03/17/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Kathryn M Fleming
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, UK.,Department of Haematology, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Paul I Dargan
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Jonathan Massie
- Department of Haematology, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Katharine Hodby
- Department of Haematology, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
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Hockenhull J, Wood DM, Fonseca F, Guareschi M, Scherbaum N, Iwanicki JL, Dart RC, Dargan PI. The association between the availability of over the counter codeine and the prevalence of non-medical use. Eur J Clin Pharmacol 2022; 78:1011-1018. [PMID: 35244726 DOI: 10.1007/s00228-021-03158-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 05/11/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE To investigate the prevalence of non-medical use (NMU) of codeine in Germany, Italy, Spain and the UK and whether availability of OTC codeine has any association with NMU of the drug. METHODS Data collected in the online Survey of Non-Medical Use of Prescription Drugs, in surveys launched in the second half of 2018 from (Germany (n = 14,969), Italy, (n = 9974), Spain (n = 9912) and the UK (n = 9819) were analysed. For each survey, the estimated prevalence and 95% confidence interval (CI) of respondents reporting NMU of prescription and/or OTC codeine within the last 12 months were calculated and compared. RESULTS The prevalence of last 12-month NMU in Spain was 12.6% (95% CI 11.7-13.6) for prescription codeine, 6.3% (5.6-7.0) for OTC codeine and 16.1% (15.1-17.3) for any codeine (prescription and/or OTC). The prevalence of last 12-month NMU in the UK was 5.4% (4.9-5.8) for prescription codeine, 4.5% (4.1-5.0) for OTC codeine and 8.3% (7.8-8.9) for any codeine (prescription and/or OTC). The prevalence of last 12-month NMU for prescription codeine was 2.1% (1.9-2.4) in Germany and 1.9% (1.7-2.2) in Italy. CONCLUSION The prevalence of last 12-month NMU of any codeine product is approximately eight times greater in Spain and four times greater in the UK compared to Germany and Italy where the drug is only available by prescription. While other factors may contribute, these findings suggest that availability of codeine OTC is associated with greater NMU.
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Affiliation(s)
- Joanna Hockenhull
- Clinical Toxicology Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - David M Wood
- Clinical Toxicology Guy's and St Thomas' NHS Foundation Trust, London, UK.,Faculty of Life Sciences and Medicine, King's College, London, UK
| | - Francina Fonseca
- Institute of Neuropsychiatry and Addictions, Parc de Salut Mar, Barcelona, Spain
| | - Marilena Guareschi
- Associazione per l'Utilizzo delle Conoscenze Neuroscientifiche a fini Sociali (AU-CNS), Pietrasanta, Italy.,Department of Neurosciences, Santa Chiara University Hospital, Pisa, Italy
| | | | | | - Richard C Dart
- Rocky Mountain Poison & Drug Center - Denver Health, Denver, CO, USA
| | - Paul I Dargan
- Clinical Toxicology Guy's and St Thomas' NHS Foundation Trust, London, UK. .,Faculty of Life Sciences and Medicine, King's College, London, UK.
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26
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Czerwinska J, Parkin MC, George C, Kicman AT, Dargan PI, Abbate V. Excretion of mephedrone and its phase I metabolites in urine after a controlled intranasal administration to healthy human volunteers. Drug Test Anal 2022; 14:741-746. [PMID: 34984836 PMCID: PMC9306721 DOI: 10.1002/dta.3214] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 12/12/2021] [Accepted: 12/13/2021] [Indexed: 11/20/2022]
Abstract
Mephedrone is a stimulant drug structurally related to cathinone. At present, there are no data available on the excretion profile of mephedrone and its metabolites in urine after controlled intranasal administration to human volunteers. In this study, six healthy male volunteers nasally insufflated 100 mg of pure mephedrone hydrochloride (Day 1). Urine was collected at different timepoints on Day 1 and then on Days 2, 3 and 30. Samples were analysed for the presence of mephedrone and its metabolites, namely, dihydro‐mephedrone, nor‐mephedrone (NOR), hydroxytolyl‐mephedrone, 4‐carboxy‐mephedrone (4‐carboxy) and dihydro‐nor‐mephedrone (DHNM), by a validated liquid chromatography‐tandem mass spectrometry method. All analytes were detected in urine, where 4‐carboxy (Cmax = 29.8 μg/ml) was the most abundant metabolite followed by NOR (Cmax = 377 ng/ml). DHNM was found at the lowest concentrations (Cmax = 93.1 ng/ml). Analytes exhibited a wide range of detection windows, but only 4‐carboxy and DHNM were detectable in all samples on Day 3, extending the detection time of mephedrone use. Moreover, mephedrone had a mean renal clearance of 108 ± 140 ml/min, and 1.3 ± 1.7% of unchanged parent drug was recovered in urine in the first 6 h post administration. It is hoped that this novel information will be useful in future studies involving mephedrone and other stimulant drugs.
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Affiliation(s)
- Joanna Czerwinska
- Department of Analytical, Environmental and Forensic Sciences, King's College London, London, UK
| | - Mark C Parkin
- Department of Analytical, Environmental and Forensic Sciences, King's College London, London, UK.,Toxicology Department, Eurofins Forensic Services, Feltham, UK
| | - Claire George
- Toxicology Department, Abbott Toxicology Ltd, Alere Toxicology (now part of Abbott), Oxfordshire, UK
| | - Andrew T Kicman
- Department of Analytical, Environmental and Forensic Sciences, King's College London, London, UK
| | - Paul I Dargan
- Clinical Toxicology, Faculty of Life Sciences and Medicine, King's College London, London, UK.,Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
| | - Vincenzo Abbate
- Department of Analytical, Environmental and Forensic Sciences, King's College London, London, UK
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27
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Dear JW, Dargan PI, Juurlink DN, Thanacoody RHK, Wood DM. Introduction to a series of Pro/Con papers in Clinical Toxicology. Br J Clin Pharmacol 2021; 88:56-57. [PMID: 34784060 DOI: 10.1111/bcp.15128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 10/15/2021] [Indexed: 11/30/2022] Open
Affiliation(s)
- James W Dear
- Pharmacology, Therapeutics and Toxicology, Centre for Cardiovascular Science, University of Edinburgh, The Queen's Medical Research Institute, Edinburgh, UK
| | - Paul I Dargan
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Clinical Toxicology, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - David N Juurlink
- Division of Clinical Pharmacology and Toxicology, Departments of Medicine and Pediatrics, University of Toronto, Toronto, Canada
| | - Ruben H K Thanacoody
- National Poisons Information Service (Newcastle unit), Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
| | - David M Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Clinical Toxicology, Faculty of Life Sciences and Medicine, King's College London, London, UK
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Harnett JT, Dargan PI, Dines AM, Archer JRH, Greene SL, Hunter LJ, Wood DM. Increasing emergency department attendances in central London with methamphetamine toxicity and associated harms. Emerg Med J 2021; 39:463-466. [PMID: 34649939 DOI: 10.1136/emermed-2020-209550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 09/22/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Methamphetamine is a stimulant drug of abuse with increasing prevalence of use worldwide leading to public health concern. While previous research by our group a decade ago found no evidence of increasing harms associated with methamphetamine use in the UK, there are conflicting data on whether or not this is still the case. This paper aims to identify trends in methamphetamine-related harms and characterise the clinical features of ED presentations involving methamphetamine with gamma-hydroxybutyrate/gamma-butyrolactone (GHB/GBL). METHODS We retrospectively interrogated a database of all toxicology-related presentations to two central London EDs, extracting data on drugs involved for presentations relating to methamphetamine between 2005 and 2018 to enable analysis of trends. Further clinical data were extracted for presentations between 2014 and 2018 to give a 4-year case series. RESULTS A total of 1244 presentations involving the use of methamphetamine were identified. The number of presentations rose from 4 in 2005 (1.9% of all recreational drug presentations) to 294 (16.2%) in 2018. A total of 850 cases were identified for the 2014-2018 case series, 94.9% were male with a median (range) age of 35.1 (16-67) years. The most common clinical features in the methamphetamine presentations were neuropsychiatric: agitation (41.5%), anxiety (35.2%), hallucinations (16.5%) and psychosis (14.8%). GHB/GBL was co-used in 54.2% of presentations and appeared to attenuate the neuropsychiatric features seen. Use of GHB/GBL was associated with a higher Poisoning Severity Score and requirement for level 2/3 (high dependency unit/intensive care unit (ICU)) care. CONCLUSION ED attendances in central London relating to methamphetamine use have risen over the last decade. Combining methamphetamine with GHB/GBL is common and is associated with a higher Poisoning Severity Score and need for ICU level care. Further work is required to establish whether further resources need to be directed at this clinical and public health problem.
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Affiliation(s)
- James T Harnett
- Emergency Department, University College London Hospitals NHS Foundation Trust, London, UK
| | - Paul I Dargan
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK.,'Faculty of Life Sciences and Medicine, King's College, London, UK
| | - Alison M Dines
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - John R H Archer
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK.,'Faculty of Life Sciences and Medicine, King's College, London, UK
| | - Shaun L Greene
- Victorian Poisons Information Centre, Austin Hospital, Melbourne, Victoria, Australia
| | - Laura J Hunter
- Emergency Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - David M Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK.,'Faculty of Life Sciences and Medicine, King's College, London, UK
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29
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Amer H, Archer JRH, Layne K, Dines AM, Wood DM, Greene SL, Dargan PI. Paracetamol toxicity in mild overdose in combination with opioids: A retrospective observational study. Br J Clin Pharmacol 2021; 88:1258-1267. [PMID: 34486149 DOI: 10.1111/bcp.15070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 08/15/2021] [Accepted: 08/17/2021] [Indexed: 11/28/2022] Open
Abstract
AIMS Toxicity in paracetamol overdose with opioid co-ingestion is poorly understood. We compared outcomes in both paracetamol-only and paracetamol-opioid overdoses to determine whether toxicity differed significantly between the groups, and to assess the utility of the ratio of measured plasma paracetamol concentration relative to the 4-hour nomogram-adjusted level (APAPpl /APAPt ). METHODS We conducted a retrospective observational study of all patients (n = 1159) presenting to 2 large UK hospitals between 2005 and 2013 with acute single-dose ingestion paracetamol overdose, with (n = 221) or without (n = 938) opioid co-ingestion. Adverse outcomes included biomarkers of hepatotoxicity and the need for extended treatment. Several outcomes were assessed in relation to the APAPpl /APAPt ratio. RESULTS Median ingested dose of paracetamol was low in both groups (10 g). Statistical comparison of the median APAPpl /APAPt ratios showed a significant difference (0.65 vs. 0.56 for the paracetamol-only and paracetamol-opioid groups respectively, P = .0329). Although there was a trend towards a lower risk of predefined toxic outcomes with opioid co-ingestion, statistical analysis did not show a significant difference, with outcomes for the paracetamol-only and paracetamol-opioid groups including the following: alanine transaminase >2× upper limit of normal, 7.7 vs. 5.7% (P = .6480); alanine transaminase >1000 IU/L, 2.4 vs. 0% (P = .2145); international normalised ratio > 1.3, 8.6 vs. 4.4% (P = .2774); and transfer to tertiary liver unit, 0.2 vs. 0% (P nonsignificant). CONCLUSION Our study does not support a change in current clinical practise beyond standard testing at 4 hours or longer post ingestion for mixed low dose paracetamol-opioid overdose.
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Affiliation(s)
- Halima Amer
- Department of Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Department of Clinical Pharmacology, University College London, London, UK
| | - John R H Archer
- Department of Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Kerry Layne
- Department of Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
| | - Alison M Dines
- Department of Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - David M Wood
- Department of Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Shaun L Greene
- Austin Toxicology Service and Victorian Poisons Information Centre, Austin Hospital, Victoria, Australia
| | - Paul I Dargan
- Department of Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
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Czerwinska J, Parkin MC, George C, Kicman AT, Dargan PI, Abbate V. Pharmacokinetics of Mephedrone and Its Metabolites in Whole Blood and Plasma after Controlled Intranasal Administration to Healthy Human Volunteers. J Anal Toxicol 2021; 45:730-738. [PMID: 32986113 DOI: 10.1093/jat/bkaa134] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 08/21/2020] [Accepted: 09/23/2020] [Indexed: 12/14/2022] Open
Abstract
Mephedrone is a popular synthetic cathinone, known for its psychostimulant effects. At present, there is no data available on the pharmacokinetics of mephedrone and its metabolites in concurrently collected whole blood and plasma samples after a controlled intranasal administration to healthy volunteers. In this study, six healthy male volunteers nasally insufflated 100 mg of pure mephedrone hydrochloride (Day 1). Whole blood and plasma samples were collected at different time points after the administration and were analyzed for the presence of mephedrone and its metabolites, dihydro-mephedrone (DHM), nor-mephedrone (NOR), hydroxytolyl-mephedrone (HYDROXY), 4-carboxy-mephedrone (4-CARBOXY) and dihydro-nor-mephedrone (DHNM), by validated liquid chromatography-tandem mass spectrometry methods. All analytes were detected in whole blood and plasma for 6 h post administration, with mephedrone and NOR also being detectable on Day 2 in some participants. 4-CARBOXY, followed by NOR, was the most abundant metabolite in both matrices. Compared to other psychostimulants, mephedrone showed rapid absorption (mean Tmax of 52.5 ± 20.7 min in plasma and 55.0 ± 18.2 min in whole blood) and elimination (mean t1/2 of 1.98 ± 0.30 h in plasma and 2.12 ± 0.33 h in whole blood). In addition, statistical analysis showed that median whole blood to plasma distribution ratios, reported here for the first time, were statistically different from 1 (unity) for mephedrone (median: 1.11), DHM (median: 1.30) and NOR (median: 0.765). It is hoped that the study will aid forensic and clinical toxicologists in detection, identification and interpretation of cases associated with mephedrone use.
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Affiliation(s)
- Joanna Czerwinska
- King's Forensics, Department of Analytical, Environmental and Forensic Sciences, King's College London, London, UK
| | - Mark C Parkin
- King's Forensics, Department of Analytical, Environmental and Forensic Sciences, King's College London, London, UK.,Eurofins Forensic Services, Toxicology Department, Teddington, UK
| | | | - Andrew T Kicman
- King's Forensics, Department of Analytical, Environmental and Forensic Sciences, King's College London, London, UK
| | - Paul I Dargan
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Clinical Toxicology, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Vincenzo Abbate
- King's Forensics, Department of Analytical, Environmental and Forensic Sciences, King's College London, London, UK
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Abstract
OBJECTIVES There is increasing evidence that Gd may be retained within the skin, bones, and solid organs in patients with normal renal function after exposure to Gd-based contrast agents (GBCAs). Here we present clinical data from 19 patients who requested referral to our clinical toxicology service for assessment of potential "Gd toxicity." MATERIALS AND METHODS Patients had undergone a median of 2 (interquartile range [IQR], 1-5) exposures to GBCAs and were reviewed at a median of 5 months (IQR, 2-8 months) after the last GBCA exposure. Patients had a clinical assessment by a clinical toxicologist, and biological samples were taken in 17 patients (89.5%). Gd concentrations were measured in these samples using inductively coupled plasma mass spectrometry. RESULTS All patients had significant comorbidities, and after an extensive clinical review, none of the reported symptoms were considered likely to be related to "Gd toxicity." Whole blood, plasma, and urine samples had detectable Gd concentrations in 69.2%, 78.6%, and 95.2% of samples, respectively. Median (IQR) concentrations of Gd were as follows: whole blood, 0.013 ng/mL (IQR, limit of detection [LOD]-0.884 ng/mL); plasma, 0.012 ng/mL (IQR, LOD-0.046 ng/mL); and spot urine, 0.304 μg/g creatinine (IQR, 0.070-3.702 μg/g creatinine). There were positive correlations between whole blood and plasma (P = 0.0024, r = 0.84), whole blood and urine (P = 0.0018, r = 0.82), and plasma and urine (P = 0.0001, r = 0.89) Gd concentrations. There was a negative correlation between Gd concentrations and the period after exposure for whole blood (P = 0.0028, r = -0.80), plasma (P = 0.0004, r = -0.86), and urine (P < 0.0001, r = -0.91). CONCLUSIONS We identified detectable Gd concentrations in biological matrices from all patients reporting exposure to GBCAs who were reviewed in our clinical toxicology outpatient clinic with concerns regarding potential "Gd toxicity"; however, there were no clinical features of toxicity present in this cohort. Further research is required to explore the pharmacokinetics and pharmacodynamics of GBCAs in patients with normal renal function and to determine the clinical significance of these detectable Gd concentrations.
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Affiliation(s)
- Kerry A Layne
- From the Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust
| | - Kishor Raja
- Viapath Analytics, King's College Hospital NHS Foundation Trust
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Blanco G, Vidler D, Roper C, Wood DM, Dargan PI, Keating L, Macfarlane R, Emmett S, Johnson G, Eddleston M, Hill SL, Thomas SHL. Acute toxicity from the synthetic cathinone N-ethylpentylone (ephylone) in the United Kingdom. Clin Toxicol (Phila) 2021; 59:1270-1273. [PMID: 33855924 DOI: 10.1080/15563650.2021.1909730] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Acute toxicity caused by New Psychoactive Substances (NPS) has created a significant burden for Emergency Departments (EDs). Here we report characteristics of people presenting with toxicity after exposure to the synthetic cathinone N-ethylpentylone (NEP). METHODS Adults presenting to hospital with severe acute toxicity after suspected NPS use were recruited between March 2015 and October 2020. Clinical features were recorded using consistent methodology and biological samples analysed using liquid chromatography-tandem mass-spectrometry. RESULTS NEP was detected in at least one sample from 9 of 893 patients recruited during the period of study, all presenting between 2016 and 2019 and 8 presenting in southern England. Commonly reported clinical features included tachycardia (6), agitation (6), confusion (6), mydriasis (5), hallucinations (4), acidosis (3) and elevated creatine kinase (3). Co-used drugs, detected in 6 patients, may have contributed to these features, but agitation and hallucinations were also reported in all 3 patients without analytical evidence of co-use. CONCLUSIONS NEP was detected infrequently in episodes of drug toxicity in the UK between 2016 and 2019, especially in southern England. Clinical characteristics of toxicity are similar to those of other cathinones, although co-use of other drugs is common and may contribute to the features observed.
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Affiliation(s)
- Georgina Blanco
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Dan Vidler
- NIHR Health Protection Research Unit for Chemical Threats and Hazards, Newcastle University, Newcastle, UK
| | - Clair Roper
- NIHR Health Protection Research Unit for Chemical Threats and Hazards, Newcastle University, Newcastle, UK
| | - David M Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Paul I Dargan
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Liza Keating
- Royal Berkshire NHS Foundation Trust, Reading, UK
| | | | - Stevan Emmett
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - Graham Johnson
- University Hospitals of Derby, Burton NHS Foundation Trust, Derby, UK
| | - Michael Eddleston
- Clinical Toxicology, Newcastle Hospitals NHS Foundation Trust, Newcastle, UK
| | - Simon L Hill
- Clinical Toxicology, Newcastle Hospitals NHS Foundation Trust, Newcastle, UK
| | - Simon H L Thomas
- NIHR Health Protection Research Unit for Chemical Threats and Hazards, Newcastle University, Newcastle, UK.,Clinical Toxicology, Newcastle Hospitals NHS Foundation Trust, Newcastle, UK
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Leaper C, Dines AM, Dargan PI, Yates C, Hovda KE, Heyerdahl F, Giraudon I, Wood DM. Impact of pregabalin co-use in patients presenting with acute heroin toxicity to the European Drug Emergencies Network Plus project. Eur J Emerg Med 2021; 28:144-146. [PMID: 33674514 DOI: 10.1097/mej.0000000000000738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Craig Leaper
- Department of Clinical Pharmacology, Chelsea and Westminster NHS Foundation Trust
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners
| | - Alison M Dines
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners
| | - Paul I Dargan
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners
- Clinical Toxicology, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Chris Yates
- Emergency Department and Clinical Toxicology Unit, Hospital Universitari Son Espases, Mallorca, Spain
| | | | - Fridtjof Heyerdahl
- Prehospital Division, Oslo University Hospital
- The Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Isabelle Giraudon
- Trends and Analysis Sector, Public Health Unit, European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal
| | - David M Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners
- Clinical Toxicology, Faculty of Life Sciences and Medicine, King's College London, London, UK
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Miró Ò, Waring WS, Dargan PI, Wood DM, Dines AM, Yates C, Giraudon I, Moughty A, O'Connor N, Heyerdahl F, Hovda KE, Vallersnes OM, Paasma R, Pold K, Jürgens G, Megarbane B, Anand JS, Liakoni E, Liechti M, Eyer F, Zacharov S, Caganova B, Bonnici J, Radenkova-Saeva J, Galicia M. Variation of drugs involved in acute drug toxicity presentations based on age and sex: an epidemiological approach based on European emergency departments. Clin Toxicol (Phila) 2021; 59:896-904. [PMID: 33724118 DOI: 10.1080/15563650.2021.1884693] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To analyse the relative percentage of acute recreational drug toxicity emergency department (ED) presentations involving the main drug groups according to age and sex and investigate different patterns based on sex and age strata. METHODS We analysed all patients with acute recreational drug toxicity included by the Euro-DEN Plus dataset (22 EDs in 14 European countries) between October 2013 and December 2016 (39 months). Drugs were grouped as: opioids, cocaine, cannabis, amphetamines, gamma-hydroxybutyrate (GHB), hallucinogens, new psychoactive substances (NPS), benzodiazepines and ketamine. Descriptive data by age and sex are presented and compared among age/sex categories and among drug families. RESULTS Of 17,371 patients were included during the 39-month period, 17,198 (99.0%) had taken at least one of the investigated drugs (median age: 31 years; 23.9% female; ethanol co-ingestion recorded in 41.5%, unknown in 31.2%; multiple drug use in 37.9%). Opioids (in 31.4% of patients) and amphetamines (23.3%) were the most frequently involved and hallucinogens (1.9%) and ketamine (1.7%) the least. Overall, female patients were younger than males, both in the whole cohort (median age 29 vs. 32 years; p < 0.001) and in all drug groups except benzodiazepines (median age 36 vs. 36 years; p = 0.83). The relative proportion of each drug group was different at every age strata and some patterns could be clearly described: cannabis, NPS and hallucinogens were the most common in patients <20 years; amphetamines, ketamine and cocaine in the 20- to 39-year group; GHB/GBL in the 30- to 39-year group; and opioids and benzodiazepines in patients ≥40 years. Ethanol and other drug co-ingestion was more frequent at middle-ages, and multidrug co-ingestion was more common in females than males. CONCLUSION Differences in the drugs involved in acute drug toxicity presentations according to age and sex may be relevant for developing drug-prevention and education programs for some particular subgroups of the population based on the increased risk of adverse events in specific sex and/or age strata.
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Affiliation(s)
- Òscar Miró
- Emergency Department, Hospital Clínic, IDIBAPS, Barcelona, Spain.,Medical School, Universitat de Barcelona, Barcelona, Spain
| | - William S Waring
- Acute Medical Unit York Teaching Hospitals NHS Foundation Trust, York, UK
| | - Paul I Dargan
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Clinical Toxicology, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - David M Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Clinical Toxicology, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Alison M Dines
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
| | - Christopher Yates
- Emergency Department, Hospital Son Espases, Palma de Mallorca, Spain
| | - Isabelle Giraudon
- European Monitoring Centre for Drugs and Drug Addiction, Lisbon, Portugal
| | - Adrian Moughty
- Emergency Department Mater, Misericordiae University Hospital, Dublin, Republic of Ireland
| | - Niall O'Connor
- Department of Emergency Medicine, Our Lady of Lourdes Hospital, Drogheda, Republic of Ireland
| | - Fridtjof Heyerdahl
- Department of Prehospital Medicine, Oslo University Hospital, Oslo, Norway
| | - Knut E Hovda
- The National CBRNe Centre of Medicine, Department of Acute Medicine, Medical Division, Oslo University Hospital, Oslo, Norway
| | - Odd M Vallersnes
- Department of General Practice, University of Oslo, Oslo Accident and Emergency Outpatient Clinic, City of Oslo Health Agency, Oslo, Norway
| | | | | | - Gesche Jürgens
- Clinical Pharmacology Unit, Zealand University Hospital Roskilde, Roskilde, Denmark.,Department and Clinical Pharmacology, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Bruno Megarbane
- Department of Medical and Toxicological Critical Care, Lariboisière Hospital, INSERM UMRS-1144, Paris-Diderot University, Paris, France
| | - Jacek S Anand
- Department of Clinical Toxicology, Medical University of Gdansk, Gdansk, Poland.,Pomeranian Centre of Toxicology, Gdansk, Poland
| | - Evangelia Liakoni
- Clinical Pharmacology and Toxicology, Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Matthias Liechti
- Division of Clinical Pharmacology and Toxicology, Basel University Hospital and University of Basel, Basel, Switzerland
| | - Florian Eyer
- Department of Clinical Toxicology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Sergej Zacharov
- Department of Occupational Medicine, Toxicological Information Centre, Charles Universtity and General Hospital University, Prague, Czech Republic
| | - Blazena Caganova
- National Toxicological Information Center, University Hospital, Bratislava, Slovakia
| | | | | | - Miguel Galicia
- Emergency Department, Hospital Clínic, IDIBAPS, Barcelona, Spain
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Waldman W, Kabata PM, Dines AM, Wood DM, Yates C, Heyerdahl F, Hovda KE, Giraudon I, Dargan PI, Sein Anand J. Rhabdomyolysis related to acute recreational drug toxicity-A Euro-DEN study. PLoS One 2021; 16:e0246297. [PMID: 33705425 PMCID: PMC7951866 DOI: 10.1371/journal.pone.0246297] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 01/17/2021] [Indexed: 11/17/2022] Open
Abstract
Background This study was conducted to retrospectively assess the relationships between: rhabdomyolysis (quantified by creatine kinase (CK) activity) and kidney injury (quantified by serum creatinine concentration), sex, age, body temperature on admission, presence of seizures, and agitation or aggression in patients presenting to the Emergency Department with acute recreational drug toxicity. We also investigated the association with the substances ingested. Methods All presentations to the 16 sentinel Euro-DEN centres in 10 European countries with acute recreational drug toxicity during the first year of the Euro-DEN study (October 2013 to September 2014) were considered. Cases that had abnormal CK activity recorded as part of routine clinical care were divided into 3 cohorts depending on peak CK activity. Cases with normal CK activity were included as a control group (4th cohort). Results Only 1,015 (18.4%) of the 5,529 Euro-DEN presentations had CK activity concentration recorded. Of this group 353 (34.8%) had also creatinine concentration measured. There were 375 (36.9%) with minor rhabdomyolysis, 69 (6.8%) with moderate rhabdomyolysis, and 24 (2.4%) with severe rhabdomyolysis; 547 (53.9%) were included in the control group. There was a positive correlation between CK activity and creatinine concentration (correlation coefficient r = 0.71, p<0.0001). There was no correlation between CK activity and body temperature at the time of presentation to the ED (correlation coefficient r = 0.07, p = 0.03). There was a positive correlation between CK activity and length of stay in the hospital (r = 0.31, p<0.001). There was no association between CK activity and the presence of seizures (p = 0.33) or agitation/aggression (p = 0.45), patients age (p = 0.4) or sex (p = 0.25). The 5 most common agents amongst patients presenting with rhabdomyolysis were: cocaine (n = 107; 22.9% presentations), amphetamine (76; 16.2%), cannabis (74; 15.8%), GHB/GBL (72; 15.4%) and heroin (67; 14.3%). The distribution of rhabdomyolysis in 5 most common drugs was (drug; patients with rhabdomyolysis, patients without rhabdomyolysis): cocaine (107, 122), cannabis (74, 117), GHB/GBL (72, 81), amphetamine (76, 66), heroin (67, 70). Conclusions Abnormal values of CK activity occurred in almost half (46.1%) of presentations to the Emergency Department with acute recreational drug toxicity in whom CK activity was measured; however, severe rhabdomyolysis is seen in only a small minority (2.4%). Those with rhabdomyolysis are at significantly higher risk of kidney injury and have a longer length of hospital stay.
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Affiliation(s)
- Wojciech Waldman
- Department of Clinical Toxicology, Medical University of Gdansk, Gdansk, Poland.,Pomeranian Centre of Toxicology, Gdansk, Poland
| | | | - Alison M Dines
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, United Kingdom
| | - David M Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, United Kingdom.,Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | | | | | | | - Isabelle Giraudon
- European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal
| | | | - Paul I Dargan
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, United Kingdom.,Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Jacek Sein Anand
- Department of Clinical Toxicology, Medical University of Gdansk, Gdansk, Poland.,Pomeranian Centre of Toxicology, Gdansk, Poland
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Fonseca F, Lenahan W, Dart RC, Papaseit E, Dargan PI, Wood DM, Guareschi M, Maremmani I, Auriacombe M, Farré M, Scherbaum N, Torrens M. Non-medical Use of Prescription Gabapentinoids (Gabapentin and Pregabalin) in Five European Countries. Front Psychiatry 2021; 12:676224. [PMID: 33995154 PMCID: PMC8113698 DOI: 10.3389/fpsyt.2021.676224] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 03/29/2021] [Indexed: 12/12/2022] Open
Abstract
Background: Non-medical use (NMU) of prescription GABA analogs (pregabalin and gabapentin) has been reported especially in opiate dependent persons. However, by now the prevalence of NMU of gabapentinoids in the general population has not been sufficiently evaluated. The aim of this research paper is to determine the prevalence of prescription GABA analog NMU and associated demographics in five European countries with special detail of Spain. Methods: The RADARS Survey of Non-Medical Use of Prescription Drugs Program (NMURx) is a harmonized series of contemporaneous cross-sectional surveys of adults conducted in multiple countries. NMURx collects data from the general population in each participating country about NMU of prescription drugs, illicit drugs, and associated demographics. NMU was defined as "using a medication without a doctor's prescription or for any reason other than what was recommended by their doctor." Responses from Spain (4Q2017, n=10,062) were analyzed in detail. Comparative data were available from France, Germany, Italy, and UK. Responses were collected using non-probability quota sampling and post-stratification population weighting was applied to reflect the national distributions of adults, based on age, gender, and census region. Rates of NMU and associated demographics were reported as rate of past 90-day NMU per 100,000 adult population with 95% confidence intervals. Results: Germany (1,197 per 100,000 adult population [95% CI: 1,004.3-1,379.1]) and United Kingdom (1,067 per 100,000 adult population [95% CI: 851.3-1,283.2]) presented the highest prevalence of gabapentinoids NMU. In Spain the prevalence of past 90 days GABA analog NMU was: 344.4, 95% (CI 204.8-484.0), with male predominance. Those who non-medically use GABA analogs had a higher prevalence of lifetime chronic pain, lifetime illicit drug use, and previous substance abuse treatment. In Spain, 20% of respondents who ever have used gabapentinoids, reported a lifetime NMU; the prevalence was higher for pregabalin 624 (6.2%) than for gabapentin 444 (4.4%). The main reasons for use were to self-treat pain and other medical conditions. Conclusions: The risk of NMU of gabapentinoids should not be neglected. Subjects with a history of chronic pain and lifetime substance use disorders had an increased risk of NMU of gabapentinoids.
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Affiliation(s)
- Francina Fonseca
- Hospital del Mar, Institut de Neuropsiquiatria i Addiccions (INAD), Barcelona, Spain.,Grup de Recerca en Addiccions, Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain.,Department of Psychiatry and Legal Medicine, Universitat Autònoma de Barcelona (UAB), Cerdanyola del Vallès, Spain
| | - William Lenahan
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO, United States
| | - Richard C Dart
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO, United States
| | - Esther Papaseit
- Clinical Pharmacology Unit, Hospital Universitari Germans Trias i Pujol (HUGTP-Germans Trias i Pujol Research Institute), Badalona, Spain.,Department of Pharmacology, Therapeutics and Toxicology, Universitat Autònoma de Barcelona (UAB), Cerdanyola del Vallès, Spain
| | - Paul I Dargan
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.,Clinical Toxicology, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - David M Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.,Clinical Toxicology, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Marilena Guareschi
- Association for the Application of Neuroscientific Knowledge to Social Aims (AU-CNS), Lucca, Italy
| | - Icro Maremmani
- Vincent P. Dole Research Group, Santa Chiara University Hospital, University of Pisa, Pisa, Italy
| | - Marc Auriacombe
- Addiction Psychiatry Department, University of Bordeaux, Bordeaux, France.,Addiction Team, Sanpsy Centre National de la Recherche Scientifique (CNRS) USR 3413, Bordeaux, France.,Pôle Addictologie et Filière Régionale, Centre Hospitalier (CH) Charles Perrens and Centre Hospitalier Universitaire (CHU) de Bordeaux, Bordeaux, France
| | - Magí Farré
- Clinical Pharmacology Unit, Hospital Universitari Germans Trias i Pujol (HUGTP-Germans Trias i Pujol Research Institute), Badalona, Spain.,Department of Pharmacology, Therapeutics and Toxicology, Universitat Autònoma de Barcelona (UAB), Cerdanyola del Vallès, Spain
| | - Norbert Scherbaum
- LVR-Hospital Essen, Department of Psychiatry and Psychotherapy, Medical Faculty, University of Duisburg-Essen, Essen, Germany
| | - Marta Torrens
- Hospital del Mar, Institut de Neuropsiquiatria i Addiccions (INAD), Barcelona, Spain.,Grup de Recerca en Addiccions, Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain.,Department of Psychiatry and Legal Medicine, Universitat Autònoma de Barcelona (UAB), Cerdanyola del Vallès, Spain
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Chan WL, Wood DM, Dargan PI. Prescription medicine misuse in the Asia-Pacific region: An evolving issue? Br J Clin Pharmacol 2020; 87:1660-1667. [PMID: 33140471 DOI: 10.1111/bcp.14638] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 10/10/2020] [Accepted: 10/17/2020] [Indexed: 12/16/2022] Open
Abstract
Prescription medicine misuse, especially misuse of opioids has become a major public healthcare issue in many developed countries such as the USA and Australia where this is associated with significant morbidity (Emergency Department visits due to acute toxicity) and mortality. In this review, we looked at the available data obtained from peer-reviewed articles and population surveys to gain an insight into the current situation in the Asia-Pacific region. There is currently limited information available, but data from subpopulation surveys in a number of countries suggests that prescription medicine misuse is likely to be an issue of concern from a public health perspective in the Asia-Pacific region. The available data suggest that misuse prevalence rates and the medicines that are commonly misused are similar to countries such as the USA and UK. Further studies are required to determine the overall prevalence of misuse, the harms associated with this and the sources of drugs being misused so that appropriate interventions can be implemented to tackle issues related to prescription medicine misuse in this region.
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Affiliation(s)
- Wui Ling Chan
- Emergency Department, Ng Teng Fong General Hospital, Singapore
| | - David M Wood
- Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Reader in Clinical Toxicology, King's College London, London, UK
| | - Paul I Dargan
- Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Clinical Toxicology, St Thomas' Hospital, London, UK
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Wood DM, Dargan PI. Regional, national and international datasets: How they improve our understanding of the acute harms associated with prescription medicine misuse. Br J Clin Pharmacol 2020; 87:1654-1659. [PMID: 33118204 DOI: 10.1111/bcp.14592] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/16/2020] [Accepted: 09/18/2020] [Indexed: 12/13/2022] Open
Abstract
Prescription medicine misuse is a significant problem in many areas of the world. Understanding the acute and chronic harms related to misuse of prescription medicines allows healthcare professionals, drug addiction treatment services and legislative authorities to determine what interventions may be beneficial to reduce these harms and protect individuals and society. However, it is difficult to obtain systematic data on the harms associated with prescription medicine misuse because of how patient visits to clinics and hospitals are recorded and coded in regional or national databases. In this review, we discuss how regional, national and international sources of information can help develop a greater understanding of the prevalence and pattern of acute harms related to prescription medicine misuse using data from ambulance attendances, emergency department presentations and poisons information services.
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Affiliation(s)
- David M Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Clinical Toxicology, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Paul I Dargan
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Clinical Toxicology, Faculty of Life Sciences and Medicine, King's College London, London, UK
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Hockenhull J, Black JC, Bletz A, Margolin Z, Olson R, Wood DM, Dart RC, Dargan PI. An evaluation of online discussion relating to nonmedical use of prescription opioids within the UK. Br J Clin Pharmacol 2020; 87:1637-1646. [PMID: 33464643 DOI: 10.1111/bcp.14603] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 08/21/2020] [Accepted: 09/30/2020] [Indexed: 01/06/2023] Open
Abstract
AIM To identify and describe the nature of online discussion relating to prescription opioids within the UK. METHODS We performed analysis of posts originating in the UK related to buprenorphine, hydrocodone, oxycodone and tramadol using Social Studio, a web-monitoring platform. The study included posts published between January 2014 and December 2016. The data were cleaned to produce a final dataset consisting only of substantive mentions, which were then categorised by defined themes. RESULTS The final dataset included a total of 17 361 substantive mentions (2936 buprenorphine, 2894 hydrocodone, 3826 oxycodone and 7705 tramadol). The most common theme for all 4 drugs was sharing experience or opinion comprising over 90% of mentions for each drug, while discussion related to polysubstance use was present in >1/4 of mentions across drug substances. Mentions related to diversion were more common for hydrocodone and oxycodone (8.1% [6.3-10.1 95% confidence interval] and 7.8% [6.5-9.2], respectively) than buprenorphine or tramadol (4.1 and 3.9% [3.5-4.3], respectively). CONCLUSION This investigation shows that there is substantial online discussion relating to a variety of nonmedical use (NMU) behaviours of prescription opioids within the UK, including for hydrocodone, which is not medically available. Web monitoring provides useful data and merits future investigation; this could include expansion to other categories of drugs and a more in-depth analysis of motivations behind NMU, both of which could add timely evidence regarding the current situation in the UK and help inform public health interventions for NMU of prescription drugs.
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Affiliation(s)
- Joanna Hockenhull
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Joshua C Black
- Rocky Mountain Poison & Drug Safety, Denver Health and Hospital Authorty, Denver, CO, USA
| | - Alex Bletz
- Rocky Mountain Poison & Drug Safety, Denver Health and Hospital Authorty, Denver, CO, USA
| | - Zachary Margolin
- Rocky Mountain Poison & Drug Safety, Denver Health and Hospital Authorty, Denver, CO, USA
| | - Rick Olson
- Rocky Mountain Poison & Drug Safety, Denver Health and Hospital Authorty, Denver, CO, USA
| | - David M Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Richard C Dart
- Rocky Mountain Poison & Drug Safety, Denver Health and Hospital Authorty, Denver, CO, USA
| | - Paul I Dargan
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
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40
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Hockenhull J, Amioka E, Black JC, Forber A, Haynes CM, Wood DM, Dart RC, Dargan PI. Non-medical use of benzodiazepines and GABA analogues in Europe. Br J Clin Pharmacol 2020; 87:1684-1694. [PMID: 32888191 DOI: 10.1111/bcp.14537] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 07/20/2020] [Accepted: 07/31/2020] [Indexed: 02/06/2023] Open
Abstract
AIMS We investigated the prevalence of non-medical use (NMU) of benzodiazepines and GABA analogues in Europe. METHODS Data were collected using the online Non-Medical Use of Prescription Drugs (NMURx) survey from France, Germany, Italy, Spain and the UK. RESULTS The study included 55 223 eligible surveys which, after post-stratification weights were applied, represented approximately 260 million European adults. Lifetime NMU of benzodiazepines was highest in Spain (6.5%, 95% CI: 6.0-7.0) and lowest in Germany (1.7%, 1.5-2.0). Lifetime NMU of GABA analogues was highest in Germany (5.4%, 5.0-5.7) and lowest in France (2.2%, 1.9-2.5) and the UK (2.2%, 1.9-2.6) While no notable difference was observed for France or the UK, there was a higher prevalence of last 12-month NMU of benzodiazepines compared to GABA analogues in Italy (2.4 times higher) and Spain (3.0 times higher) and a higher prevalence of NMU of GABA analogues compared to benzodiazepines in Germany (2.6 times higher). CONCLUSION This study shows that there is variation in NMU of benzodiazepines and GABA analogues among countries. Of particular interest is the high incidence of GABA analogue NMU in Germany and benzodiazepine NMU in Spain. Further research to identify factors and motivations responsible for the higher prevalence observed are essential to inform public health policies in those countries.
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Affiliation(s)
- Joanna Hockenhull
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Elise Amioka
- Rocky Mountain Poison & Drug Safety, Denver Health and Hospital Authority, Denver, CO, USA
| | - Joshua C Black
- Rocky Mountain Poison & Drug Safety, Denver Health and Hospital Authority, Denver, CO, USA
| | - Alyssa Forber
- Rocky Mountain Poison & Drug Safety, Denver Health and Hospital Authority, Denver, CO, USA
| | - Colleen M Haynes
- Rocky Mountain Poison & Drug Safety, Denver Health and Hospital Authority, Denver, CO, USA
| | - David M Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Richard C Dart
- Rocky Mountain Poison & Drug Safety, Denver Health and Hospital Authority, Denver, CO, USA
| | - Paul I Dargan
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
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Noseda R, Schmid Y, Scholz I, Liakoni E, Liechti ME, Dargan PI, Wood DM, Dines AM, Yates C, Heyerdahl F, Hovda KE, Giraudon I, Ceschi A, Anand L, Anseeuw K, Badaras R, Bonnici J, Brvar M, Burke R, Caganova B, Eyer F, Galicia M, Geith S, Gillebeert J, Grenc D, Gorozia K, Jaffal K, Jürgens G, Konstari J, Kutubidze S, Laubner G, Liguts V, Lyphout C, Mégarbane B, Miró Ò, Moughty A, O'Connor N, Paasma R, Perez JO, Perminas M, Persett PS, Põld K, Puiguriguer J, Radenkova-Saeva J, Rulisek J, Sopirala R, Stašinskis R, Surkus J, Toth I, Vallersnes OM, Vigorita F, Waldman W, Waring WS, Zacharov S. MDMA-related presentations to the emergency departments of the European Drug Emergencies Network plus (Euro-DEN Plus) over the four-year period 2014–2017. Clin Toxicol (Phila) 2020; 59:131-137. [DOI: 10.1080/15563650.2020.1784914] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Roberta Noseda
- Division of Clinical Pharmacology and Toxicology, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Yasmin Schmid
- Division of Clinical Pharmacology and Toxicology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Irene Scholz
- Clinical Pharmacology and Toxicology, Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Institute of Pharmacology, University of Bern, Bern, Switzerland
| | - Evangelia Liakoni
- Clinical Pharmacology and Toxicology, Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Institute of Pharmacology, University of Bern, Bern, Switzerland
| | - Matthias E. Liechti
- Division of Clinical Pharmacology and Toxicology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Paul I. Dargan
- Clinical Toxicology, Guy’s and St Thomas’ NHS Foundation Trust and King’s Health Partners, London, UK
- Clinical Toxicology, Faculty of Life Sciences and Medicine, King’s College London, London, UK
| | - David M. Wood
- Clinical Toxicology, Guy’s and St Thomas’ NHS Foundation Trust and King’s Health Partners, London, UK
- Clinical Toxicology, Faculty of Life Sciences and Medicine, King’s College London, London, UK
| | - Alison M. Dines
- Clinical Toxicology, Guy’s and St Thomas’ NHS Foundation Trust and King’s Health Partners, London, UK
| | - Christopher Yates
- Emergency Department and Clinical Toxicology Unit, Hospital Universitari Son Espases, Mallorca, Spain
| | - Fridtjof Heyerdahl
- Prehospital Division, Oslo University Hospital, Oslo, Norway
- The Norwegian Air Ambulance Foundation, Bodo, Norway
| | - Knut E. Hovda
- The Norwegian CBRNE Centre of Medicine, Department of Acute Medicine, Oslo University Hospital, Oslo, Norway
| | - Isabelle Giraudon
- European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal
| | - Alessandro Ceschi
- Division of Clinical Pharmacology and Toxicology, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, Zurich, Switzerland
- Faculty of Biomedical Sciences, University of Southern Switzerland, Lugano, Switzerland
| | - Lukasz Anand
- Department of Clinical Toxicology, Medical University of Gdansk, Poland
| | - Kurt Anseeuw
- Department of Emergency Medicine, ZNA Stuivenberg, Antwerp, Belgium
| | | | | | - Miran Brvar
- Centre for Clinical Toxicology and Pharmacology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Rachel Burke
- Emergency Department, Mater Misericordiae University Hospital, Dublin 7, Republic of Ireland
| | - Blazena Caganova
- National Toxicological Information Centre, University Hospital, Bratislava, Slovakia
| | - Florian Eyer
- Department of Clinical Toxicology, Klinikum Rechts der Isar, Technical University of Munich, Germany
| | | | - Stefanie Geith
- Department of Clinical Toxicology, Klinikum Rechts der Isar, Technical University of Munich, Germany
| | - Johan Gillebeert
- Department of Emergency Medicine, ZNA Stuivenberg, Antwerp, Belgium
| | - Damjan Grenc
- Centre for Clinical Toxicology and Pharmacology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Ketevan Gorozia
- Archangel St. Michael Multiprofile Clinical Hospital, Tbilisi, Georgia
| | - Karim Jaffal
- Department of Medical and Toxicological Critical Care, Lariboisiere Hospital, INSERM UMRS-1144, Paris-Diderot University, Paris, France
| | - Gesche Jürgens
- Zealand University Hospital Roskilde, Clinical Pharmacology Unit, Roskilde, Denmark
| | | | - Soso Kutubidze
- Archangel St. Michael Multiprofile Clinical Hospital, Tbilisi, Georgia
| | - Gabija Laubner
- Republic Vilnius University Hospital, Vilnius, Lithuania
| | | | | | - Bruno Mégarbane
- Department of Medical and Toxicological Critical Care, Lariboisiere Hospital, INSERM UMRS-1144, Paris-Diderot University, Paris, France
| | - Òscar Miró
- Emergency Department, Hospital Clınic, University of Barcelona, Catalonia, Spain
| | - Adrian Moughty
- Emergency Department, Mater Misericordiae University Hospital, Dublin 7, Republic of Ireland
| | - Niall O'Connor
- Department of Emergency Medicine, Our Lady of Lourdes Hospital, Drogheda, County Louth, Republic of Ireland
| | | | - Juan Ortega Perez
- Clinical Toxicology Unit, Emergency Department, Hospital Son Espases, Palma de Mallorca, Balearic Island, Spain
| | - Marius Perminas
- Hospital of Lithuanian University of Health Sciences (LSMU), Kauno klinikos, Kaunus, Lithuania
| | - Per Sverre Persett
- Department of Acute Medicine, Medical Division, Oslo University Hospital, Norway
| | - Kristiina Põld
- Emergency Medicine Department, North-Estonia Medical Centre, Tallinn, Estonia
| | - Jordi Puiguriguer
- Clinical Toxicology Unit, Emergency Department, Hospital Son Espases, Palma de Mallorca, Balearic Island, Spain
| | | | - Jan Rulisek
- Department of Anesthesia and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital, U Nemocnice 2, 120 00 Prague 2, Czech Republic
| | - Radhika Sopirala
- Department of Emergency Medicine, Our Lady of Lourdes Hospital, Drogheda, County Louth, Republic of Ireland
| | | | - Jonas Surkus
- Hospital of Lithuanian University of Health Sciences (LSMU), Kauno klinikos, Kaunus, Lithuania
| | | | - Odd Martin Vallersnes
- Department of General Practice, University of Oslo, Oslo, Norway
- Oslo Accident and Emergency Outpatient Clinic, City of Oslo Health Agency, Oslo, Norway
| | | | - Wojciech Waldman
- Department of Clinical Toxicology, Medical University of Gdansk, Poland
- Pomeranian Centre of Toxicology, Gdansk, Poland
| | - W. Stephen Waring
- Acute Medical Unit, York Teaching Hospitals NHS Foundation Trust, York, UK
| | - Sergej Zacharov
- Toxicological Information Centre, Department of Occupational Medicine, 1st Faculty of Medicine, Charles University and General University Hospital, Na Bojisti 1, 120 00 Prague 2, Czech Republic
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Layne KA, Dargan PI, Dines AM, Leaper C, Yates C, Hovda KE, Heyerdahl F, Archer JRH, Giraudon I, Wood DM. Acute toxicity related to misuse (nonmedical use) of tramadol: Experience of the European Drug Emergencies Network Plus. Br J Clin Pharmacol 2020; 87:1668-1675. [PMID: 32503085 DOI: 10.1111/bcp.14408] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 05/05/2020] [Accepted: 05/24/2020] [Indexed: 01/09/2023] Open
Abstract
Following the development of the tramadol crisis currently affecting countries in the Middle East, and Africa, there has been increasing international interest in the regulation of tramadol. This study investigates the misuse of tramadol in patients presenting to emergency departments across Europe. Data from 32 emergency departments in 21 countries were extracted from the Euro-DEN Plus database for the 4-year period from 1 January 2014 to 31 December 2017. Of the reported 24,957 emergency department presentations, tramadol misuse was reported in 105 (0.4% presentations). Tramadol misuse was most common in Bratislava (Slovakia; n = 11, 7.5% of all presentations to this centre), Riga (Latvia; n = 4, 4.9%) and Munich (Germany; n = 17, 2.9%). On arrival, 14 (13.3%) of presentations were in coma/Glasgow coma score ≤ 8 and 9 of these had a respiratory rate <12 breaths/min. These presentations potentially pose a significant burden on emergency departments with a large proportion requiring admission to hospital for ongoing care.
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Affiliation(s)
- Kerry A Layne
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, UK
| | - Paul I Dargan
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Clinical Toxicology, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Alison M Dines
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, UK
| | - Craig Leaper
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, UK
| | - Christopher Yates
- Emergency Department and Clinical Toxicology Unit, Hospital Universitari Son Espases, Mallorca, Spain
| | - Knut Erik Hovda
- The Norwegian CBRNe Centre of Medicine, Oslo University Hospital, Oslo, Norway
| | - Fridtjof Heyerdahl
- Prehospital Division, Oslo University Hospital, Oslo, Norway.,The Norwegian Air Ambulance Foundation, Oslo, Norway
| | - John R H Archer
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Clinical Toxicology, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Isabelle Giraudon
- European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal
| | - David M Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
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43
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Hockenhull J, Black JC, Haynes CM, Rockhill K, Dargan PI, Dart RC, Wood DM. Nonmedical use of benzodiazepines and Z-drugs in the UK. Br J Clin Pharmacol 2020; 87:1676-1683. [PMID: 32472941 DOI: 10.1111/bcp.14397] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 05/13/2020] [Accepted: 05/15/2020] [Indexed: 12/31/2022] Open
Abstract
AIMS To estimate prevalence of last 12-month nonmedical use (NMU) of benzodiazepines and Z-drugs (the nonbenzodiazepine hypnotics zaleplon, zolpidem and zopiclone) in the UK. METHODS Data were collected using the Non-Medical Use of Prescription Drugs survey with poststratification weighting applied to be representative of the UK population (≥16 years). Participants were questioned about whether they had nonmedically used benzodiazepines and/or Z-drugs in the last 12-months and from where they had obtained the drug (including via a prescription, or illicitly from a friend/family member, a dealer or via the internet). Additional questions were asked about last 12-month use of illicit drugs (cannabis, cocaine, 3,4-methylenedioxymethylamphetamine [MDMA], non-pharmaceutical amphetamine, crack cocaine and/or heroin). RESULTS The study included 10 006 eligible participants representing approximately 52 927 000 UK adults. The estimated prevalence of past 12-month NMU of any benzodiazepine and/or Z-drug was 1.2% (95% confidence interval: 1.0-1.5) corresponding to approximately 635 000 adults; amongst this group only an estimated 4.6% (1.2-8.0) had NMU of both a benzodiazepine and a Z-drug. The highest prevalence of NMU for only Z-drugs was among those who had used heroin in the last 12-months (5.4%, 2.7-10.5), whilst the highest prevalence of NMU for only benzodiazepines was among those who had used illicit stimulants in the last 12-months: cocaine (5.9%, 3.8-8.9), amphetamine (5.6%, 3.1-10.0) and MDMA (5.2%, 3.1-8.8). The drug non-medically used was more commonly acquired without than with a prescription for both only benzodiazepines (70.2%, 59.4-81.1 compared to 51.3%, 41.5-64.6) and only Z-drugs (75.6%, 61.6-89.7 compared to 33.9%, 16.9-51.0). CONCLUSION There is little overlap between benzodiazepine and Z-drug NMU suggesting distinct nonmedical use of the drugs; future studies need to explore whether this relates to personal preference, drug availability or other factors. A significant proportion are acquiring these drugs for NMU without a prescription, so without guidance and monitoring from a medical practitioner. While the dangers of mixing benzodiazepines and heroin/other opioids are well documented, there is a paucity of data regarding concomitant NMU of benzodiazepines and stimulant drugs, or NMU of Z-drugs and opioids, and, given the prevalence of these combinations, this requires further investigation.
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Affiliation(s)
- Joanna Hockenhull
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Joshua C Black
- Rocky Mountain Poison & Drug Safety, Denver Health and Hospital Authority, Denver, CO, USA
| | - Colleen M Haynes
- Rocky Mountain Poison & Drug Safety, Denver Health and Hospital Authority, Denver, CO, USA
| | - Karilynn Rockhill
- Rocky Mountain Poison & Drug Safety, Denver Health and Hospital Authority, Denver, CO, USA
| | - Paul I Dargan
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Richard C Dart
- Rocky Mountain Poison & Drug Safety, Denver Health and Hospital Authority, Denver, CO, USA
| | - David M Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
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Lavergne V, Ghannoum M, Gosselin S, Goldfarb D, Nolin TD, Dargan PI, Roberts DM. Assessing the effect of extracorporeal treatments for lithium poisoning. Br J Clin Pharmacol 2020; 87:214-215. [PMID: 32501620 DOI: 10.1111/bcp.14367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 04/07/2020] [Accepted: 05/05/2020] [Indexed: 11/29/2022] Open
Affiliation(s)
- Valery Lavergne
- Department of Medicine, Sacré-Coeur Hospital, University of Montreal, Montreal, Canada
| | - Marc Ghannoum
- Universite de Montreal Faculte de Medecine, Specialized Medicine, Montreal, Canada
| | - Sophie Gosselin
- Hôpital Charles-Lemoyne, Department of Emergency, Medicine, Montreal, Canada
| | - David Goldfarb
- Nephrology Division, NYU Langone Health, New York, New York, USA.,Nephrology Division, VA NY, Harbor Healthcare System Manhattan Campus, New York, New York, USA
| | - Thomas D Nolin
- Department of Pharmacy and Therapeutics, Center of Clinical Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, USA
| | - Paul I Dargan
- General Medicine and Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Darren M Roberts
- Departments of Clinical Pharmacology, Toxicology and Renal Medicine, St Vincent's Hospital Sydney, Darlinghurst, NSW, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
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Archer JRH, Mendes F, Hudson S, Layne K, Dargan PI, Wood DM. Evaluation of long-term detection trends of new psychoactive substances in pooled urine from city street portable urinals (London, UK). Br J Clin Pharmacol 2020; 86:517-527. [PMID: 32050035 DOI: 10.1111/bcp.14239] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 01/03/2020] [Accepted: 01/12/2020] [Indexed: 11/28/2022] Open
Abstract
AIMS To evaluate the long-term trends of new psychoactive substance (NPS) detection in pooled urine samples collected across a city centre. METHODS Pooled urine samples from portable stand-alone urinals were collected on a monthly basis over 5.5 years (July 2013-December 2018) across a city centre. These were analysed using a high-performance liquid chromatography system, interfaced to a high-resolution accurate mass spectrometer. Data were processed against a database containing over 2000 drugs/metabolites including over 800 NPS. RESULTS In total, 44 NPS were detected with variation over time including cathinones (15, 34.1%), synthetic cannabinoids (8, 18.2%) and 21 (47.7%) other NPS. Since the introduction of the UK Psychoactive Substances Act (May 2016) cathinone detection has decreased with minimal detection over the last 4 months of the study. Synthetic cannabinoids were not detected on a regular basis until July 2016 with a subsequent variable detection frequency. There was a consistent, low level detection frequency of all other NPS throughout the study, but which appears to have increased alongside the decrease in cathinone detection. CONCLUSION Pooled urine analysis of samples taken from portable urinals in a city centre can be used as an effective monitoring tool to determine long-term trends in the use of NPS. The results of this study demonstrate the impact of the Psychoactive Substances Act and reflect the findings of population surveys and clinical studies. Triangulation of these data with other data sources will enable greater insight into the NPS phenomenon.
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Affiliation(s)
- John R H Archer
- Department of Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Fiona Mendes
- Department of Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
| | - Simon Hudson
- Laboratory and Managed Services, LGC, Fordham, UK
| | - Kerry Layne
- Department of Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
| | - Paul I Dargan
- Department of Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - David M Wood
- Department of Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
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46
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Wood DM, Dargan PI. The challenge of the novel psychoactive substances: How have we responded and what are the implications of this response? Br J Clin Pharmacol 2020; 86:407-409. [PMID: 32144815 PMCID: PMC7080627 DOI: 10.1111/bcp.14236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 01/21/2020] [Accepted: 02/05/2020] [Indexed: 11/28/2022] Open
Affiliation(s)
- David M Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
- Clinical Toxicology, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Paul I Dargan
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
- Clinical Toxicology, Faculty of Life Sciences and Medicine, King's College London, London, UK
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Abstract
BACKGROUND Loperamide is a mu-opioid receptor agonist that is available as an over-the-counter anti-motility agent in the US and UK; recommended maximum doses of 12-16 mg/day. Anecdotal reports of non-medical use (NMU) have increased over the past decade with supra-therapeutic doses (70-800 mg/day) associated with cardiotoxicity. Little data exists on the prevalence of loperamide NMU. AIM The aim of this study was to determine the prevalence of loperamide NMU in the UK and US and to describe characteristics of non-medical loperamide users. DESIGN The Researched, Abuse, Diversion and Addiction Related Surveillance (RADARS® ) Survey of Nonmedical Use of Prescription Drugs (NMURx) was utilized to study NMU of loperamide among the adult population in the UK and US in 2017. The RADARS® NMURx is anonymous and self-administered online. METHODS A total of 40,029 completed surveys were included (10,019 from the UK and 30,010 from the US). Respondents were asked questions about medical and NMU of loperamide, frequency of and reasons for NMU, route of use problematic drug use markers, and demographics. RESULTS Prevalence of lifetime loperamide use (95% CI) and lifetime NMU of loperamide were: UK 28.5% (27.67-29.4), and 0.66% (0.5-0.8), respectively; US 33.7% (33.1-34.2), and 5.19% (4.9-5.5), respectively. Problematic drug use markers were elevated in those who reported NMU of loperamide in both the UK and US, however high-risk use was more prevalent in the UK than in the US. CONCLUSION NMU of loperamide is common. In the current international environment of opioid addiction involving both therapeutic and illicit opioids, awareness of the NMU of loperamide is important.
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Affiliation(s)
- N E Webb
- Clinical Toxicology Department, St Thomas' Hospital, Westminster Bridge Road London, London, UK
| | - D M Wood
- Clinical Toxicology Department, St Thomas' Hospital, Westminster Bridge Road London, London, UK
- Faculty of Life Sciences and Medicine, King's College London, Strand, London, London, UK
| | - J C Black
- Rocky Mountain Poison and Drug Center, 1391 Speer Boulevard, Suite 600, Denver, CO, USA
| | - E Amioka
- Rocky Mountain Poison and Drug Center, 1391 Speer Boulevard, Suite 600, Denver, CO, USA
| | - R C Dart
- Rocky Mountain Poison and Drug Center, 1391 Speer Boulevard, Suite 600, Denver, CO, USA
| | - P I Dargan
- Clinical Toxicology Department, St Thomas' Hospital, Westminster Bridge Road London, London, UK
- Faculty of Life Sciences and Medicine, King's College London, Strand, London, London, UK
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48
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Abstract
Background: There are reports of prescription stimulants being purchased online for use as cognitive enhancers or "smart drugs." Objectives: The aim of this study was to investigate availability of modafinil and methylphenidate from internet suppliers from the perspective of a typical United Kingdom (UK) based customer. Methods: Using European Monitoring Center for Drugs and Drug Addiction (EMCDDA) internet snapshot methodology, we undertook an English language internet snapshot survey in July-August 2018 to gather information on the availability and price of modafinil and methylphenidate from online retailers. Results: A total of 55 modafinil and 14 methylphenidate websites were identified from which the drug could be purchased without a prescription. Minimum purchase quantities ranged from 10 to 90 tablets for modafinil and 1-1,005 tablets for methylphenidate with no apparent upper limit to the number that could be purchased. The price per tablet varied from £0.38-5.31 for modafinil and £0.16-5.70 for methylphenidate. Free shipping was offered if more than a certain amount was spent on 46 (83.6%) modafinil and 7 (50.0%) methylphenidate websites and discounts were offered on 43 (78.2%) modafinil and 4 (28.6%) methylphenidate websites. Conclusions: Modafinil and methylphenidate are widely available to purchase via internet from the UK without a prescription. The pricing on websites encourages users to buy greater quantities to qualify for discounts and free shipping. The quantities available suggest these purchases may be used in greater amounts than would be legitimately prescribed, increasing the risk of misuse or diversion to other individuals.
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Affiliation(s)
- Joanna Hockenhull
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - David M Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Clinical Toxicology, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Paul I Dargan
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Clinical Toxicology, Faculty of Life Sciences and Medicine, King's College London, London, UK
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49
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Czerwinska J, Jang M, Costa C, Parkin MC, George C, Kicman AT, Bailey MJ, Dargan PI, Abbate V. Detection of mephedrone and its metabolites in fingerprints from a controlled human administration study by liquid chromatography-tandem mass spectrometry and paper spray-mass spectrometry. Analyst 2020; 145:3038-3048. [DOI: 10.1039/c9an02477h] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Mephedrone and one of its metabolites have been detected for the first-time in fingerprints collected from a controlled human mephedrone administration study.
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Affiliation(s)
- Joanna Czerwinska
- King's Forensics
- Department of Analytical
- Environmental and Forensic Sciences
- King's College London
- London
| | - Min Jang
- Department of Chemistry
- University of Surrey
- UK
| | - Catia Costa
- Surrey Ion Beam Centre
- University of Surrey
- UK
| | - Mark C. Parkin
- King's Forensics
- Department of Analytical
- Environmental and Forensic Sciences
- King's College London
- London
| | | | - Andrew T. Kicman
- King's Forensics
- Department of Analytical
- Environmental and Forensic Sciences
- King's College London
- London
| | - Melanie J. Bailey
- Department of Chemistry
- University of Surrey
- UK
- Surrey Ion Beam Centre
- University of Surrey
| | - Paul I. Dargan
- Clinical Toxicology
- Guy's and St Thomas’ NHS Foundation Trust and King's Health Partners
- London
- UK
- Clinical Toxicology
| | - Vincenzo Abbate
- King's Forensics
- Department of Analytical
- Environmental and Forensic Sciences
- King's College London
- London
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50
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Layne KA, Wood DM, Dargan PI. Gadolinium-based contrast agents – what is the evidence for ‘gadolinium deposition disease’ and the use of chelation therapy? Clin Toxicol (Phila) 2019; 58:151-160. [DOI: 10.1080/15563650.2019.1681442] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Kerry A. Layne
- General Medicine, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- Clinical Toxicology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- Faculty of Life Sciences and Medicine, King’s College London, London, UK
| | - David M. Wood
- General Medicine, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- Clinical Toxicology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- Faculty of Life Sciences and Medicine, King’s College London, London, UK
| | - Paul I. Dargan
- General Medicine, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- Clinical Toxicology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- Faculty of Life Sciences and Medicine, King’s College London, London, UK
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