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Siefried KJ, Freeman G, Roberts DM, Lindsey R, Rodgers C, Ezard N, Brett J. Inpatient GHB withdrawal management in an inner-city hospital in Sydney, Australia: a retrospective medical record review. Psychopharmacology (Berl) 2023; 240:127-35. [PMID: 36508055 DOI: 10.1007/s00213-022-06283-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 11/19/2022] [Indexed: 12/15/2022]
Abstract
RATIONALE Regular consumption of gamma-hydroxybutyrate (GHB) may result in a dependence syndrome that can lead to withdrawal symptoms. There are limited data on medications to manage GHB withdrawal. OBJECTIVES To examine characteristics associated with delirium and discharge against medical advice (DAMA), in the context of implementing a GHB withdrawal management protocol at an inner-city hospital in 2020. METHODS We retrospectively reviewed records (01 January 2017-31 March 2021), and included admissions that were ≥ 18 years of age, admitted for GHB withdrawal, and with documented recent GHB use. Admissions were assessed for demographics, medications administered, features of delirium, ICU admission, and DAMA. Exploratory analyses were conducted to examine factors associated (p < 0.2) with features of delirium and DAMA. RESULTS We identified 135 admissions amongst 91 patients. Medications administered included diazepam (133 admissions, 98.5%), antipsychotics (olanzapine [70 admissions, 51.9%]), baclofen (114 admissions, 84%), and phenobarbital (8 admissions, 5.9%). Features of delirium were diagnosed in 21 (16%) admissions. Delirium was associated with higher daily GHB consumption prior to admission, while duration of GHB use, time from presentation to first dose of diazepam, and concomitant methamphetamine use were inversely associated with delirium. DAMA occurred amongst 41 (30%) admissions, and was associated with a longer time from presentation to first dose of baclofen, while being female and receiving a loading dose of diazepam were inversely associated. CONCLUSIONS This study adds to the literature in support of the safety and feasibility of diazepam and baclofen for the management of GHB withdrawal. Prospective, randomised trials are required.
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Bogun B, Campbell M, Marr B, Larsen A, Philip L, Johnson C. Fantasy islands - The emergence of NMP in GBL-containing liquids in New Zealand. Forensic Sci Int 2021; 329:111093. [PMID: 34773817 DOI: 10.1016/j.forsciint.2021.111093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 10/27/2021] [Accepted: 10/31/2021] [Indexed: 11/29/2022]
Abstract
Over the last few years there has been a dramatic increase in the amount of "Fantasy" type drugs seized in New Zealand, with gamma-butyrolactone (GBL) being by far the most prevalent. In 2018, N-methyl-2-pyrrolidone (NMP) was detected in a liquid, along with GBL, for the first time in New Zealand. Since this seizure, the number of seizures containing mixtures of GBL and NMP that have been submitted for analysis by New Zealand authorities have significantly increased, with 82% of submitted samples containing GBL also containing NMP. Analysis of these liquids showed that the majority had GBL and NMP purities of approximately 60-70% and 30-40%, respectively. Subsequent investigations by New Zealand authorities revealed a potential source of these liquids being a diverted legitimate industrial product. The health and psychoactive effects of NMP, along with GBL and NMP mixtures, are unknown. Health statistics in New Zealand have indicated increased harm from GBL use over the last few years.
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Affiliation(s)
- Ben Bogun
- Institute of Environmental Science and Research Limited, Mt Albert Science Centre, 120 Mt Albert Road, Sandringham, Auckland 1025, New Zealand.
| | - Madeleine Campbell
- National Drug Intelligence Bureau, Police National Headquarters, 180 Molesworth Street, Wellington 6011, New Zealand.
| | - Brooke Marr
- Institute of Environmental Science and Research Limited, Mt Albert Science Centre, 120 Mt Albert Road, Sandringham, Auckland 1025, New Zealand.
| | - Annie Larsen
- Institute of Environmental Science and Research Limited, Mt Albert Science Centre, 120 Mt Albert Road, Sandringham, Auckland 1025, New Zealand.
| | - Liam Philip
- Institute of Environmental Science and Research Limited, Mt Albert Science Centre, 120 Mt Albert Road, Sandringham, Auckland 1025, New Zealand.
| | - Cameron Johnson
- Institute of Environmental Science and Research Limited, Mt Albert Science Centre, 120 Mt Albert Road, Sandringham, Auckland 1025, New Zealand.
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Galicia M, Dargan PI, Dines AM, Yates C, Heyerdahl F, Hovda KE, Giraudon I, Wood DM, Miró Ò. Clinical relevance of ethanol coingestion in patients with GHB/GBL intoxication. Toxicol Lett 2019; 314:37-42. [PMID: 31301370 DOI: 10.1016/j.toxlet.2019.07.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 05/16/2019] [Accepted: 07/01/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Ethanol intake can increase the sedative effects of gamma-hydroxybutyrate/gamma-butyrolactone (GHB/GBL), although the real clinical impact is unknown. We studied the clinical impact of the co-ingestion of ethanol in patients presenting to the Emergency Department (ED) with acute toxicity related to GHB/GBL use. METHOD We performed a secondary analysis of the Euro-DEN Plus Registry (14 countries, 22 EDs) which includes 17,371 consecutive patients presenting to the ED with acute recreational drug toxicity over 39 consecutive months (October 2013 - December 2016). We compared the epidemiological and clinical characteristics and ED management of patients identified as presenting with acute toxicity related to lone GHB/GBL (Group A) or GHB/GBL combined with ethanol (Group B) without other concomitant drugs. RESULTS A total of 609 patients were included (age 32 (8) years; 116 women (19%); Group A: 183 patients and Group B: 426). The most common features were reduction in consciousness (defined as Glasgow Coma Score <13 points: 56.1%) and agitation/aggressiveness (33.6%). Those with ethanol co-ingestion were younger patients (Group A/B: 31.5/33.1 years, p = 0.029) and ethanol co-ingestion was associated with a lower frequency of bradycardia (23.5%/15.7%, p = 0.027) and more frequent arrival at the ED by ambulance (68.3/86.6%; p < 0.001), reduction in consciousness (58.9%/49.1%; p = 0.031), need for treatment in the ED (49.2%/60.4%; p = 0.011), use of sedatives (20.1%/12.8%; p = 0.034), admission to critical care units (22.4%/55.3%; p < 0.001), and longer hospital stay (stay longer than 6 h: 16.9%/28.4%; p = 0.003). CONCLUSIONS Co-ingestion of ethanol increases the adverse effects of patients intoxicated by GHB/GBL, leading to greater depression of consciousness, need for treatment, admission to the ICU and longer hospital stay.
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Affiliation(s)
- Miguel Galicia
- Emergency Department, Hospital Clínic, Barcelona, IDIBAPS, Barcelona, Spain.
| | - Paul I Dargan
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, United Kingdom; Clinical Toxicology, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Alison M Dines
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, United Kingdom
| | - Christopher Yates
- Servicio de Urgencias, Hospital Son Espases, Palma de Mallorca, Spain
| | - Fridtjof Heyerdahl
- The National CBRNe Centre of Medicine, Department of Acute Medicine, Medical Division, Oslo University Hospital, Oslo, Norway
| | - Knut Erik Hovda
- The National CBRNe Centre of Medicine, Department of Acute Medicine, Medical Division, Oslo University Hospital, Oslo, Norway
| | - Isabella 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, United Kingdom; Clinical Toxicology, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Òscar Miró
- Emergency Department, Hospital Clínic, Barcelona, IDIBAPS, Barcelona, Spain; Medical School, University of Barcelona, Spain
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Raposo RS, de Almeida MCMD, da Fonseca MMR, Cesário MT. Feeding strategies for tuning poly (3-hydroxybutyrate-co-4-hydroxybutyrate) monomeric composition and productivity using Burkholderia sacchari. Int J Biol Macromol 2017; 105:825-33. [PMID: 28735003 DOI: 10.1016/j.ijbiomac.2017.07.111] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 07/16/2017] [Accepted: 07/17/2017] [Indexed: 01/22/2023]
Abstract
Poly(3-hydroxybutyrate-co-4-hydroxybutyrate) (P(3HB-4HB)) co-polymers were produced at bench-scale in fed-batch cultivations by Burkholderia sacchari from glucose (main carbon-source) and gamma-butyrolactone (GBL) as co-substrate. As P(3HB-4HB) properties highly depend on the 4-hydroxybutyrate (4HB) molar fraction, it is advantageous to have a thorough knowledge of the process in order to promote the production of the targeted final product. In this work, polymers with a 4HB molar percentage ranging from 1.5 to 8.4% (mol/mol) were obtained as consequence of a fine tuning of the fed-batch operation conditions, namely regarding the co-substrate feeding rate and its addition time, as GBL is toxic to B. sacchari cells. The best results regarding both the 4HB incorporation (molar%) and the co-polymer productivity (7.1% and 1.1g/(L.h) respectively) were reached when a pulse of GBL (<10g/L) was added early in the accumulation phase followed by a constant GBL addition at a rate similar to that of consumption so that a steady co-substrate concentration in the medium was maintained.
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Miró Ò, Galicia M, Dargan P, Dines AM, Giraudon I, Heyerdahl F, Hovda KE, Yates C, Wood DM, Liakoni E, Liechti M, Jürgens G, Pedersen CB, O'Connor N, Markey G, Moughty A, Lee C, O'Donohoe P, Sein Anand J, Puiguriguer J, Homar C, Eyer F, Vallersnes OM, Persett PS, Chevillard L, Mégarbane B, Paasma R, Waring WS, Põld K, Rabe C, Kabata PM. Intoxication by gamma hydroxybutyrate and related analogues: Clinical characteristics and comparison between pure intoxication and that combined with other substances of abuse. Toxicol Lett 2017; 277:84-91. [PMID: 28579487 DOI: 10.1016/j.toxlet.2017.05.030] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 05/28/2017] [Accepted: 05/29/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To study the profile of European gamma-hydroxybutyrate (GHB) and gammabutyrolactone (GBL) intoxication and analyse the differences in the clinical manifestations produced by intoxication by GHB/GBL alone and in combination with other substances of abuse. METHOD We prospectively collected data on all the patients attended in the Emergency Departments (ED) of the centres participating in the Euro-DEN network over 12 months (October 2013 to September 2014) with a primary presenting complaint of drug intoxication (excluding ethanol alone) and registered the epidemiological and clinical data and outcomes. RESULTS We included 710 cases (83% males, mean age 31 years), representing 12.6% of the total cases attended for drug intoxication. Of these, 73.5% arrived at the ED by ambulance, predominantly during weekend, and 71.7% consumed GHB/GBL in combination with other substances of abuse, the most frequent additional agents being ethanol (50%), amphetamine derivatives (36%), cocaine (12%) and cannabis (8%). Among 15 clinical features pre-defined in the project database, the 3 most frequently identified were altered behaviour (39%), reduced consciousness (34%) and anxiety (14%). The severity ranged from mild cases requiring no treatment (308 cases, 43.4%) to severe cases requiring admission to intensive care (103 cases, 14.6%) and mechanical ventilation (49 cases, 6.9%). No deaths were reported. In comparison with only GHB/GBL consumption, patients consuming GHB/GBL with co-intoxicants presented more vomiting (15% vs. 3%, p<0.001) and cardiovascular symptoms (5.3% vs. 1.5%, p<0.05), a greater need for treatment (59.8% vs. 48.3%, p<0.01) and a longer ED stay (11.3% vs. 3.6% patients with ED stay >12h, p<0.01). CONCLUSIONS The profile of the typical GHB/GBL-intoxicated European is a young male, requiring care for altered behaviour and reduced level of consciousness, mainly during the weekend. The clinical features are more severe when GHB is consumed in combination with other substances of abuse.
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Busardò FP, Kyriakou C, Marchei E, Pacifici R, Pedersen DS, Pichini S. Ultra-high performance liquid chromatography tandem mass spectrometry (UHPLC-MS/MS) for determination of GHB, precursors and metabolites in different specimens: Application to clinical and forensic cases. J Pharm Biomed Anal 2017; 137:123-131. [PMID: 28110168 DOI: 10.1016/j.jpba.2017.01.022] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [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: 10/02/2016] [Revised: 12/27/2016] [Accepted: 01/07/2017] [Indexed: 11/25/2022]
Abstract
Gamma-hydroxybutyric acid (GHB) acts as a precursor and metabolite of the inhibitory central nervous system (CNS) neurotransmitter gamma-aminobutyric acid (GABA). Sodium salt of GHB has been used as a medication for narcolepsy and alcohol withdrawal. Moreover, GHB and its precursor gamma-butyrolactone (GBL), are illegal recreational drugs of abuse. A procedure based on ultra-high-performance liquid chromatography tandem mass spectrometry has been developed and validated in plasma, urine, cerebrospinal fluid and hair for acute and chronic exposure to GHB and in seized preparations coming from black market. In biological matrices, GHB was investigated together with its glucuronide (GHB-Gluc) as a potential marker of exposure, GABA as endogenous precursor and metabolite and GBL as eventual exogenous precursor. GBL was sought together with GHB in illegal preparations. Chromatographic separation was achieved at ambient temperature using a reverse-phase column and an isocratic elution with two solvents: 0.1% formic acid in water and pure methanol. Multiple reaction monitoring (MRM) was used. The method was linear for all analytes under investigation from limit of quantification (LOQ) to 500μgmL-1 plasma, urine and cerebrospinal fluid, from LOQ to 100ngmg-1 hair and from LOQ to 10mgmL-1 illicit preparations with good correlation coefficients (r2=0.99) for all substances. Recovery of analytes under investigation was always higher than 75% and intra-assay and inter-assay precision and accuracy were always better than 15%. The validated method was then successfully applied to real specimens from either forensic (one post-mortem urine sample taken from a GHB fatal intoxication case) or clinical cases (cerebrospinal fluid, plasma and hair samples collected from narcoleptic patients under sodium oxybate treatment). Finally, illicit preparations, seized by police forces were also checked for GHB amount and eventual presence of prodrug GBL.
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Affiliation(s)
- Francesco Paolo Busardò
- Unit of Forensic Toxicology (UoFT), Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, V. Le Regina Elena 336, 00161 Rome, Italy.
| | - Chrystalla Kyriakou
- Unit of Forensic Toxicology (UoFT), Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, V. Le Regina Elena 336, 00161 Rome, Italy
| | - Emilia Marchei
- National Centre on Addiction and Doping, Istituto Superiore di Sanità, V. le Regina Elena 299, 00161 Rome, Italy
| | - Roberta Pacifici
- National Centre on Addiction and Doping, Istituto Superiore di Sanità, V. le Regina Elena 299, 00161 Rome, Italy
| | - Daniel Sejer Pedersen
- Faculty of Health and Medical Sciences, Department of Drug Design and Pharmacology, Jagtvej 162, University of Copenhagen, 2100 Copenhagen, Denmark
| | - Simona Pichini
- National Centre on Addiction and Doping, Istituto Superiore di Sanità, V. le Regina Elena 299, 00161 Rome, Italy
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Lingford-Hughes A, Patel Y, Bowden-Jones O, Crawford MJ, Dargan PI, Gordon F, Parrott S, Weaver T, Wood DM. Improving GHB withdrawal with baclofen: study protocol for a feasibility study for a randomised controlled trial. Trials 2016; 17:472. [PMID: 27677382 PMCID: PMC5039898 DOI: 10.1186/s13063-016-1593-9] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [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: 04/05/2016] [Accepted: 07/27/2016] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND GHB (gamma-hydroxybutyrate) and its pro-drugs GBL (gamma-butyrolactone) and 1,4-butanediol (1,4-BD) are central nervous system depressants whose street names include 'G' and 'liquid ecstasy'. They are used recreationally predominately for their stimulant and pro-sexual effects or for sedation to help with sleep and/or to 'come down' after using stimulant recreational drugs. Although overall population prevalence is low (0.1 %), in some groups such as men who have sex with men, GHB/GBL use may reach 20 %. GHB/GBL dependence may be associated with severe withdrawal with individuals presenting either acutely to emergency departments or to addiction services for support. Benzodiazepines are currently prescribed for GHB/GBL detoxification but do not prevent all complications, such as behavioural disinhibition, that may require hospitalisation or admission to a high dependency/intensive care unit. The GABAB receptor mediates most effects of GHB/GBL and the GABAB agonist, baclofen, has shown promise as an adjunct to benzodiazepines in reducing withdrawal severity when prescribed both during withdrawal and as a 2-day 'preload' prior to detoxification. The key aim of this feasibility study is provide information about recruitment and characteristics of the proposed outcome measure (symptom severity, complications including delirium and treatment escalation) to inform an application for a definitive randomised placebo controlled trial to determine the role of baclofen in the management of GHB/GBL withdrawal and whether starting baclofen 2 days earlier improves outcomes further. METHODS/DESIGN This is a prospective, randomised, double-blind, placebo-controlled feasibility study that will recruit participants (aged over 18 years) who are GHB/GBL-dependent and wish to undergo planned GHB/GBL detoxification or are at risk of acute withdrawal and are inpatients requiring unplanned withdrawal. We aim to recruit 88 participants: 28 unplanned inpatients and 60 planned outpatients. During detoxification we will compare baclofen 10 mg three times a day with placebo as an adjunct to the usual benzodiazepine regimen. In the planned outpatient arm, we will also compare a 2-day preload of baclofen 10 mg three times a day with placebo. Ratings of GHB/GBL withdrawal, sleep, depression, anxiety as well as GHB/GBL use will be collected. The main data analyses will be descriptive about recruitment and characterising the impact of adding baclofen to the usual benzodiazepine regimen on measures and outcomes of GHB/GBL withdrawal to provide estimates of variability and effect size. A qualitative approach will evaluate research participant and clinician acceptability and data collected to inform cost-effectiveness. DISCUSSION This feasibility study will inform a randomised controlled trial to establish whether adding baclofen to a benzodiazepine regimen reduces the severity and complications of GHB/GBL withdrawal. TRIAL REGISTRATION ISRCTN59911189 . Registered 14 October 2015. PROTOCOL v3.1, 1 February 2016.
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Affiliation(s)
- Anne Lingford-Hughes
- Central North West London NHS Foundation Trust's Club Drug Clinic, 69 Warwick Rd, London, SW5 9HB, UK. .,Centre for Psychiatry, Division of Brain Sciences, Imperial College London, Burlington Danes Building, Hammersmith Hospital site, Du Cane Rd, London, W12 0NN, UK.
| | - Yash Patel
- Central North West London NHS Foundation Trust's Club Drug Clinic, 69 Warwick Rd, London, SW5 9HB, UK
| | - Owen Bowden-Jones
- Central North West London NHS Foundation Trust's Club Drug Clinic, 69 Warwick Rd, London, SW5 9HB, UK
| | - Mike J Crawford
- Central North West London NHS Foundation Trust's Club Drug Clinic, 69 Warwick Rd, London, SW5 9HB, UK.,Centre for Psychiatry, Division of Brain Sciences, Imperial College London, Burlington Danes Building, Hammersmith Hospital site, Du Cane Rd, London, W12 0NN, UK
| | - Paul I Dargan
- Guy's and St. Thomas NHS Foundation Trust, London, UK.,Faculty of Life Sciences and Medicine, King's College, London, UK
| | - Fabiana Gordon
- Statistical Advisory Service, School Of Public Health, Imperial College London, London, UK
| | - Steve Parrott
- Department of Health Sciences, The University of York, York, UK
| | - Tim Weaver
- Department of Mental Health, Social Work and Integrative Medicine, Middlesex University, London, UK
| | - David M Wood
- 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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Heytens L, Neels H, Van Regenmortel N, van den Brink W, Henckes M, Schouwers S, Dockx G, Crunelle CL. Near-fatal persistent anion- and osmolal-gap acidosis due to massive gamma-butyrolactone/ethanol intoxication. Ann Clin Biochem 2014; 52:283-7. [PMID: 25205856 DOI: 10.1177/0004563214553278] [Citation(s) in RCA: 5] [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] [Indexed: 11/16/2022]
Abstract
We report a case of an ethanol and massive gamma-butyrolactone (GBL) intoxication, the precursor of the recreational drug gamma-hydroxybutyric acid (GHB), resulting in life-threatening metabolic acidosis (pH 6.5) with a highly increased anion- and osmolal gap. Rapid analysis using gas chromatography revealed a GHB plasma concentration of 4400 mg/L, far above the upper limit concentration of 1000 mg/L found in adult fatalities attributed to GBL. Full recovery was established following supportive treatment including haemodialysis. This is the first report of a combined ethanol/GBL intoxication as a cause of high serum anion- and osmolal-gap metabolic acidosis.
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Affiliation(s)
- Luc Heytens
- Department of Intensive Care, Sint-Augustinus Hospital, Wilrijk, Belgium
| | - Hugo Neels
- Toxicological Center, University of Antwerp, Antwerp, Belgium Laboratory for Clinical Chemistry and Toxicology, ZNA Stuivenberg, Antwerp, Belgium
| | | | - Wim van den Brink
- Amsterdam Institute for Addiction Research, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Manu Henckes
- Department of Nephrology, Sint-Augustinus Hospital, Wilrijk, Belgium
| | - Sofie Schouwers
- Clinical Laboratory, Sint-Augustinus Hospital, Wilrijk, Belgium
| | - Greet Dockx
- Laboratory for Clinical Chemistry and Toxicology, ZNA Stuivenberg, Antwerp, Belgium
| | - Cleo L Crunelle
- Toxicological Center, University of Antwerp, Antwerp, Belgium
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