Poison Information Center Research Articles

Descriptive analysis of poisoning cases involving attention deficit hyperactivity disorder medications in Hong Kong.

The number of poisoning cases involving attention deficit hyperactivity disorder (ADHD) medications has reportedly risen with their increased use. However, there is limited relevant evidence from Asia. We analysed the characteristics of poisoning events involving these medications in Hong Kong. We retrieved data regarding ADHD medication-related poisoning cases from the Hong Kong Poison Information Centre and conducted a descriptive analysis of the demographic information and poisoning information including sources of cases, exposure reason, exposure location, and outcome. The HKPIC data were linked with the Hospital Authority Clinical Data Analysis and Reporting System (CDARS) via de-identified Accident and Emergency numbers of public hospitals to investigate clinical characteristics. We also retrieved ADHD medication prescription records from the CDARS, then compared trends between poisoning cases and ADHD medication use. We identified 72 poisoning cases involving ADHD medications between 2009 and 2019, of which approximately 70% occurred in the affected individual's residence; most were intentional poisoning events (65.3%). No statistically significant association was observed between ADHD medication prescription trends and poisoning events involving ADHD medications. Of the 66 cases (91.7%) successfully linked to CDARS, 40 (60.6%) occurred in individuals with ADHD (median age: 14 years); 26 (39.4%) occurred in individuals who lacked ADHD (median age: 33 years) but displayed higher rates of other mental disorders including depression and anxiety. No significant correlation was evident between ADHD medication prescriptions and poisoning events involving ADHD medications. However, medication management and caregiver education must be emphasised to prevent potential poisoning events.

The epidemiology of acute methamphetamine toxicity presenting to emergency departments in Hong Kong

Introduction: Recreational use of methamphetamine is increasing worldwide, but epidemiology studies from Asia are lacking. We aimed to characterise the trends, drug use pattern, clinical presentations and health services utilisation of acute methamphetamine toxicity presenting to emergency departments and the current practice of emergency department psychosocial interventions in Hong Kong. Methods: This was a secondary analysis of a retrospective study on emergency department patients reported to the Hong Kong Poison Information Centre between 2010 and 2019 for acute toxicity related to recreational methamphetamine use. We studied the trend using a negative binominal regression model. Results: During the study period, 1225 episodes (involved 979 patients; 68.9% men; with a median age of 33.0 years) were reported. Acute methamphetamine toxicity did not increase significantly (odds ratio = 1.10, 95% confidence interval = 0.86–1.40, p = 0.46). Polysubstance abuse predominated. Many patients developed hypokalaemia (24.0%), rhabdomyolysis (17.2%), acute kidney injury (9.4%) and myocardial injury (4.7%); psychotic symptoms including auditory hallucination (23.8%) and paranoid delusion (21.1%); various acute behavioural disturbances and injuries. Overall, 66 patients required intensive care and 14 patients died. Only a minority of the patients were referred to social workers and voluntary drug treatment and rehabilitation services. Conclusion: Methamphetamine has a significant impact on physical and mental health in Hong Kong. Our findings highlight the need for screening for hypokalaemia, rhabdomyolysis, acute kidney injury, myocardial injury and psychosis in methamphetamine users and support policies that address polysubstance abuse, prevent drug use through continued public education and strengthen the referral system by integrating substance abuse services at the emergency department.

An outbreak of severe coagulopathy in northern Israel among users of illicit synthetic cannabinoids adulterated with brodifacoum

Introduction Adulteration of illicit drugs is a well-known phenomenon that may expose consumers to unexpected adverse effects. We report a large outbreak of severe coagulopathy in northern Israel during nine months in 2021–2022 among users of synthetic cannabinoids adulterated with a long-acting anticoagulant, brodifacoum. Methods We performed a retrospective cohort study based on data extracted from the Israeli National Poison Information Center database and from electronic medical patient records at three participating hospitals. Confiscated drug samples and blood samples obtained at admission in a subgroup of patients were tested for the presence of long-acting anticoagulants. Results We identified 98 patients affected by the outbreak. All patients had a prolonged international normalized ratio on admission, and in 69%, the blood was non-coagulating. For patients treated in the three participating centers (n = 72), the presenting complaint was overt bleeding in 79% of patients, most commonly in the urinary (53%) and gastrointestinal tracts (50%). The most severe complications were intracranial bleeding (4%), hemothorax (3%), pericardial bleeding (1%), and four patients died. Brodifacoum was detected in all available blood samples (median concentration 207 µg/L, interquartile range 112–349 μg/L, range 45–1,118 µg/L), and the drug samples contained both brodifacoum and the synthetic cannabinoid ADB-BUTINACA. All patients were treated with high-dose phytomenadione (vitamin K1) and additionally by packed red blood cell transfusions, fresh frozen plasma, and/or 4-factor prothrombin complex concentrate when indicated. The most frequent phytomenadione (vitamin K1) dose regimen was initially 20 mg intravenously every eight hours, and at discharge, 20 mg orally three times daily. Conclusions Outbreaks of severe coagulopathies in users of synthetic cannabinoids adulterated with a long-acting anticoagulant continue to erupt in different regions of the world. Rapid recognition of an outbreak requires a high index of suspicion when confronting young, otherwise healthy subjects with otherwise unexplained severe coagulopathy.

Common calls to a poisons information centre by general practitioners.

Poisoning in the community is common and can occasionally result in serious outcomes, such as organ damage and death. Many cases of poisoning can be successfully managed in the primary caresetting. This article describes common calls theQueensland Poisons Information Centre (Qld PIC) receives from general practices and provides information onthe management of poisoning in thecommunity. Common calls to the Qld PIC from general practice include calls about exposure to paracetamol and household cleaning products, with ocular exposure to toxins common. Most cases of poisoning can be managed supportively. Decontamination, observation or antidote therapy may be required in some cases. Ocular exposure to poisons requires irrigation, examination and, occasionally, referral for specialist ophthalmological assessment. The PIC can help general practitioners (GPs) with risk assessment and management advice to ensure the best outcomes for their patients. GPs cancontact the PIC on 13 11 26.

Epic Fail? Try Again

We read with interest the manuscript titled “Failure of Crotalidae Immune F(ab’)2 Equine Antivenom to Achieve Control in a Southern Pacific Rattlesnake Envenomation” by Levine et al. The authors indicate that their patient “failed to respond adequately to F(ab’)2AV” because his initially unmeasurable platelet count reached a maximum of 102,000/μL at 56 hours after envenomation. We have several concerns with this conclusion. Adequate platelet response in the setting of venom-induced hemotoxicity is not universally defined. Although some patients may have complete reversal of thrombocytopenia after a single antivenom dose, others may have increasing platelet numbers but never achieve a platelet count of >150,000/μL. A 2011 study by Yin et al1Yin S. Kokko J. Lavonas E. et al.Factors associated with difficulty achieving initial control with crotalidae polyvalent immune fab antivenom in snakebite patients.Acad Emerg Med. 2011; 18: 46-52Crossref PubMed Scopus (21) Google Scholar suggested that it “may not be reasonable to attempt to completely control” thrombocytopenia. Antivenom may have been underdosed initially. F(ab’)2AV is dosed at 10 vials over 1 hour and repeated hourly until initial control is obtained, as evidenced by the halt of proximal swelling and improvement in laboratory markers. However, as above, there is no consensus on specific numeric goals.2Anavip [Package Insert]. Franklin, TN: Rare Disease Therapeutics, Inc.Google Scholar Although the patient received 10 vials initially, his next dose approximately 1 to 2 hours later was only 4 vials. He received the remaining 6 vials after approximately 9 hours. His platelet count continued to increase. The trend suggests that earlier administration may have prevented persistent thrombocytopenia. After viper envenomation, platelets may be sequestered, pro- and anti-aggregated, and destroyed through multiple mechanisms, leading to recurrent or refractory thrombocytopenia, which is difficult to predict in the absence of routine venomic studies on individual patients. This inability to reliably predict the mechanism of thrombocytopenia results in the inability to predict platelet response to antivenom.3Shen C. Liu M. Mackeigan D.T. et al.Viper venoms drive the macrophages and hepatocytes to sequester and clear platelets: novel mechanism and therapeutic strategy for venom-induced thrombocytopenia.Arch Toxicol. 2021; 95: 3589-3599Crossref PubMed Scopus (4) Google Scholar,4De Queiroz M.R. de Sousa B.B. da Cunha Pereira D.F. et al.The role of platelets in hemostasis and the effects of snake venom toxins on platelet function.Toxicon. 2017; 133: 33-47Crossref PubMed Scopus (45) Google Scholar Owing to platelet sequestration and aggregation, antivenom should quickly reverse thrombocytopenia. However, with platelet destruction or consumption, levels would not increase until the patient could synthesize more platelets de novo. This patient may have had ongoing platelet consumption to repair venom-induced tissue damage, yet the authors did not describe the progression of cytotoxicity. The lack of fibrinogen trend also makes the inference of ongoing venom effect problematic. Rattlesnake antivenom is best suited not to resolve thrombocytopenia but to reverse defibrination, so the significance of persistent thrombocytopenia in the absence of fibrinogen levels is unclear.5Dudley S. Smelski G. Massey D.J. et al.Fashionably late: A characterization of late coagulopathies in rattlesnake envenomations between Fab and F (ab’) 2 antivenoms.Toxicon. 2022; 212: 49-54Crossref Scopus (0) Google Scholar Twenty-three years of unpublished data from the Arizona Poison and Drug Information Center shows that persistent thrombocytopenia after antivenom is common regardless of which of the two commercially available antivenoms is used (FabAV or F[ab’]2AV). Considering cases with thrombocytopenia during initial hospital stay, 197 of 556 (35.43%) FabAV patients and 39 of 107 (36.45%) F(ab’)2AV patients were discharged with a platelet count of < 150,000/μL. Some patients did not develop thrombocytopenia until after discharge. Among FabAV patients, 106 of 472 (22.46%) developed delayed thrombocytopenia compared with only 7 of 130 (5.38%) F(ab’)2AV patients. Similar rates of persistent thrombocytopenia in the inpatient setting suggest that destruction of platelets occurs in some patients regardless of antivenom manufacturer. The difference in delayed thrombocytopenia suggests that the longer half-life of F(ab’)2AV continues to protect against thrombocytopenia compared with FabAV. Finally, the authors did not provide an illustration of the patient’s overall clinical picture throughout his hospital stay, including progression of edema, pain, and coagulation factors. Isolated thrombocytopenia is not an indication to provide more antivenom as bleeding due to thrombocytopenia is unlikely if there is no defibrination. A patient with stabilization of other indicators, despite persistent thrombocytopenia, has had an adequate response to antivenom. As always in medicine, treat the patient, not the number.

Repeated poisonings in Denmark – a nationwide study

Objective Poisonings contribute significantly to morbidity and mortality of patients. Some patients have numerous contacts to a poison information center, indicating repeated poisoning exposures. Information on the involved substances is necessary to explore methods to prevent self-harm and reduce mortality. The objective of this study was to characterize the patient population with repeated poison exposures in Denmark and identify the substances involved. Methods This study was a retrospective cohort study of enquiries to the nationwide Danish Poison Information Centre and the Danish National Patient Registry. The databases were used to identify patients with more than five individual poisoning episodes within a 12-month-period between 1 January 2013, and 31 December 2017. Results One hundred and thirty-seven patients and 995 patients met the inclusion criteria in the Danish Poison Information Centre and the Danish National Patient Registry, respectively. The majority were women (82.5% and 66.3% for the Danish Poison Information Centre and the Danish National Patient Registry cohorts, respectively). The mean age was 24.7 and 29.5 years. Psychiatric comorbidities were frequent with 74.5% and 67.0% suffering from personality disorders and 70.1% and 54.5% from affective disorders in the Danish Poison Information Centre and the Danish National Patient Registry cohorts, respectively. One thousand seven hundred and fifty-two poisoning episodes were identified in the Danish Poison Information Centre database, and the most common types of substance were ‘pharmaceuticals’ (1,420 episodes). The most common medications ingested were quetiapine, paracetamol and cyclizine. Median number of contacts to the Danish Poison Information Centre was 10. Patients with one or more poisoning episodes involving cyclizine had on average 11.4 poisoning episodes involving cyclizine. In the Danish National Patient Registry cohort 80.9% were alive after 10 years compared to 97.7% in the background population. Conclusion and Implications Most poisonings were intentional and occurred among younger women. Psychiatric comorbidity was frequent. Most often, pharmaceuticals were the toxic substance, mainly quetiapine, paracetamol and cyclizine. Changing the status of cyclizine from over the counter to prescription only medication, and implementing stricter rules for prescribing quetiapine, could limit future poisoning incidences.

Significant Increase in Deliberate Self-Poisonings Among Adolescents During the Second Year of the COVID-19 Pandemic

PurposeThe COVID-19 pandemic has been associated with a decline in mental health of adolescents. The aim of this study was to analyze the rate of deliberate self-poisonings (DSPs) among adolescents reported to the Dutch Poisons Information Center before and during the COVID-19 pandemic. MethodsA retrospective study from 2016 until 2021 was performed to characterize DSPs among adolescents, and to analyze trends in the number of DSPs. All DSPs among adolescents with the age of 13 up to and including 17 years were included. DSP characteristics included: age, gender, bodyweight, used substance, dose, and treatment advice. Trends in the number of DSPs were analyzed using time series decomposition and Seasonal Autoregressive Integrated Moving Average models. ResultsSix thousand nine hundred fifteen DSPs in adolescents were recorded from January first 2016 until December 31st 2021. Females were involved in 84% of adolescent DSPs. A strong increase in the number of DSPs was observed in 2021 (45% increase compared to 2020), which deviated from the predicted trend based on previous years. This increase was most prominent in 13-, 14-, and 15-year-old female adolescents. Commonly involved drugs were paracetamol, ibuprofen, methylphenidate, fluoxetine, and quetiapine. The contribution of paracetamol rose from 33% in 2019 to 40% in 2021. DiscussionThe strong increase in the number of DSPs during the second year of the COVID-19 pandemic suggests that long-term containment measures such as quarantines, lockdowns, and school closures may enhance self-harm behavior among adolescents, especially among younger females (13–15 years of age), with a preference for paracetamol as DSP substance.

High Incidence of Signs of Neuropathy and Self-Reported Substance Use Disorder for Nitrous Oxide in Patients Intoxicated with Nitrous Oxide

Introduction: The number of patients with excessive nitrous oxide (N₂O) use and neurological disorders has been rising, indicating an addictive potential of N₂O. We studied the incidence of self-reported substance use disorder (SUD)-related symptoms, signs of neuropathy, and the patterns of use in N₂O-intoxicated patients. Methods: The Dutch Poisons Information Center (DPIC) provides information by telephone on the management of intoxications to healthcare professionals. Retrospective data on signs of neuropathy and patterns of use were collected for all N₂O intoxications reported to the DPIC in 2021 and 2022. Frequent and heavy use were self-reported as “often/frequent/weekly use” and as “use of tanks or >50 balloons/session,” respectively. From this cohort, we included patients with excessive N₂O use or signs of neuropathy in a prospective observational cohort study. Online surveys were sent 1 week, 1 month, and 3 months after DPIC consultation. The survey included the drug use disorder questionnaire (validated to measure self-reported substance abuse [SA] and substance dependence [SD] based on Diagnostic and Statistical Manual of Mental Disorders [DSM]-IV-TR criteria) and questions on patterns of use and signs of neuropathy. DSM-IV-TR criteria were translated to DSM-V criteria to score for mild, moderate, or severe SUD, with 2–3, 4–5, or ≥6 symptoms, respectively. Results: We included 101 N₂O-intoxicated patients in the retrospective study. Of these, 41% showed signs of neuropathy (N = 41), 53% used N₂O tanks to fill balloons (N = 53), 71% used them frequently (N = 72), and 76% used them heavily (N = 77). We included 75 patients in the prospective study and 10 (13%) completed the first survey. All 10 patients fulfilled the criteria for SA and SD (DSM-IV-TR, median number of questions answered “yes” = 10/12), all used N₂O tanks to fill balloons, and 90% (N = 9) experienced signs of neuropathy. After 1 and 3 months, 6/7 and 1/1 patients, respectively, continued to fulfill SA and SD criteria. Translating to DSM-V criteria, 1/10 patients fulfilled the criteria for (self-reported) mild SUD, 1/10 patients for moderate SUD, and 8/10 patients for severe SUD, 1 week after consultation. Conclusion: The high proportion of N₂O-intoxicated patients reporting frequent and heavy use of N₂O indicates an addictive potential of N₂O. Although follow-up rate was low, all patients fulfilled self-reported SA, SD (DSM-IV-TR), and SUD (DSM-V) criteria for N₂O. Somatic healthcare professionals treating patients with N₂O intoxications should be aware of possible addictive behavior in patients. The screening, brief intervention, and referral to treatment approach should be considered to treat patients with self-reported SUD symptoms.

Sharp increase in self-poisonings among adolescent girls during the Covid-19 pandemic: Findings from Norwegian registry data.

Sharp increase in self-poisonings among adolescent girls during the Covid-19 pandemic: Findings from Norwegian registry data.

A retrospective evaluation of mushroom ingestions in 421 dogs in Norway (2011-2022).

Mushroom poisoning may result in a variety of signs ranging from mild, mostly gastroenteritis, to organ failure and death. To increase the knowledge of prevalence, treatment and outcome in dogs, information regarding mushroom ingestion was collected. This retrospective study analysed all inquiries of mushroom ingestion in dogs to the Norwegian Poison Information Center from 2011 to 2022. Mushrooms were identified by a mycologist or Norwegian-certified mushroom expert. Differences in mushroom species, clinical findings, treatments and outcome were evaluated. A total of 421 mushroom ingestions in dogs were included. The mushrooms were identified as non-poisonous in 45% of cases. The most frequently involved toxin group was gastrointestinal mushrooms, followed by muscarinic mushrooms and mushrooms containing isoxazoles. About 64% of cases were managed at home, 33% were hospitalised and received treatment, and 3% were observed by a veterinarian without treatment. The survival rate was 98.6%, with death occurring after ingestion of Amanita muscaria, Cortinarius rubellus, Amanita virosa, Clitocybe rivulosa and Inocybe sp. This study demonstrated the importance of rapid and accurate identification of the mushroom. This could prevent delays in therapeutic intervention and avoid unnecessary treatment of these dogs. With early, correct identification of mushrooms, our results demonstrated a good prognosis for dogs after ingestion.

The epidemiology of wild mushroom poisoning in Israel

ABSTRACT Wild mushroom (macrofungi) picking has become a popular activity in Israel in recent years. Besides the estimated 135 edible species, the mycobiota of Israel includes also around 65 poisonous and potentially dangerous species. We conducted a long-term retrospective study to monitor the frequency, severity, seasonal character, species composition, and geographic distribution of mushroom exposure and poisoning in Israel. Using data collected by the Israel Poison Information Center in Rambam Health Care Campus, Haifa, during the years 2010–2021, we report that only 4% of cases of exposures due to biological agents were caused by mushrooms. Males were significantly (P < 0.004) more affected than females. Most cases involved either above 18 years of age (41%) or below the age of 6 years (39%). Most of the children under 6 years of age did not develop signs or symptoms of toxicity. During 2017–2021, 128 cases (82.5%) involved the consumption of raw mushrooms, mostly by children under 6 years of age. The most common season of mushroom exposure was rainy winters (P < 0.05). Mushrooms collected from irrigated lawns in the summer also posed a risk. Ingestion of Chlorophyllum molybdites was the leading mushroom ingestion in summer and that of Inocybe species in winter. Our study contributes to improved awareness of mushroom exposure and poisoning patterns among the Israeli population.

An Indonesian slimming drug with undeclared ingredients causing harm.

This paper reports the presence of undeclared drugs in the herbal slimming supplement Sulami®. The four cases of the adverse drug reactions related to Sulami® were reported to the Dutch Pharmacovigilance Centre (Lareb) or the Dutch Poisons Information Centre (DPIC). The analysis of all four collected samples revealed adulteration with sibutramine and canrenone. Both drugs can cause serious adverse drug reactions. From a legal point of view, it is clear that Sulami® does not meet the legal requirement for safety. As defined in the European General Food Law Regulation, food business operators are responsible for food safety. This also applies to online store owners who sell herbal preparations. Thus, it is clear that it is forbidden to sell Sulami® on the European and Dutch market. Collaboration between involved national authorities makes it possible to identify risky products. This allows the nationally responsible regulators to take targeted action. They can call on users to report sell points what makes it possible to arrest the sellers and confiscate the dangerous products. Beyond the national, also, the European enforcement organizations should take legal measures where possible, to protect public health. The Heads of Food Safety Agencies Working Group on Food Supplements "an Initiative on European level" is a good example of efforts to improve consumer safety.

Hong Kong poison information centre: Annual report 2020

Background:The Hong Kong Poison Information Centre has provided consultation service to healthcare professionals and collected epidemiological data on poisoning in Hong Kong since 2005.Objective:To analyse and report the poisoning data of Hong Kong Poison Information Centre in 2020 during the COVID‐19 pandemic.Methods:A retrospective review of all poisoning cases recorded in the Poison Information and Clinical Management System of Hong Kong Poison Information Centre in 2020.Results:A total of 3633 poisoning cases were analysed. Compared to 2019 (pre‐COVID era), there was a reduction of ~10% of total poisoning cases recorded (383 cases), with a majority (&gt; 90%) of reduction from poisoning cases with no clinical effect (353 cases). A greater proportion of reduction was observed among the children (0–12 years), patients with general unintentional poisoning, poisoning due to therapeutic error and food poisoning. An increased number of cases was noted from abusive use, adverse herb/proprietary Chinese medicine reaction and poisoning related to household bleaches. Teenage (13–19 years) poisoning seemed to be unaffected by the COVID‐19 pandemic and the previously observed increasing trend continued (up to 11.8% of total poisoning cases this year). Despite a total reduction in poisoning cases recorded, the number of deaths increased by 37% from 35 in 2019 to 48 in 2020 (mortality rate 1.5%). A total of seven interesting cases were discussed.Conclusion:This 15th annual report provides updated epidemiological information on poisoning patterns in Hong Kong during the COVID‐19 pandemic. It also highlighted important changes and possible effects of the COVID‐19 pandemic on poisoning in Hong Kong in comparison with our previous reports.

Anticoagulant rodenticide ingestion: Who will develop coagulopathy?

Introduction:Development of coagulopathy after anticoagulant rodenticide ingestion varies among patients. This study aimed to identify factors that were associated with coagulopathy after anticoagulant rodenticide ingestion.Methods:This was a retrospective cohort study, conducted in the Hong Kong Poison Information Centre. All patients who reported rodenticide exposure and presented to the Accident and Emergency Department from 1 January 2010 to 31 December 2019 were recruited. Coagulopathy was defined as International Normalized Ratio of 1.3 or above.Results:One hundred sixty‐nine patients were included in the final analysis. The median age was 44 years old. Forty‐nine patients developed coagulopathy (International Normalized Ratio ⩾1.3). Univariate analysis (at p &lt; 0.05) showed that age (p = 0.003), ingestion of first‐generation anticoagulant rodenticide (p = 0.017), ingestion of more than one pack (p &lt; 0.001), intentional ingestion (p = 0.002), hypoalbuminemia (p &lt; 0.001), elevated alanine aminotransferase level (p = 0.041) and abnormal estimated glomerular filtration rate (p = 0.005) on presentation, and co‐ingestion with paracetamol (p = 0.018) were associated with coagulopathy after anticoagulant rodenticide ingestion. Among these, ingestion of more than one pack (p &lt; 0.001; odds ratio = 19.8; 95% confidence interval = 6.78–65.7), ingestion of first‐generation anticoagulant rodenticide (p = 0.006; odds ratio = 5.2; 95% confidence interval = 1.96–15.2), hypoalbuminemia (p &lt; 0.001; odds ratio = 22.4; 95% confidence interval = 6.17–99.0) and elevated alanine aminotransferase level on presentation (p = 0.039; odds ratio = 7.11; 95% confidence interval = 1.58–33.1) were statistically significant in the multivariate analysis.Conclusion:Ingestion of more than one pack and ingestion of first‐generation anticoagulant rodenticides were significantly associated with the development of coagulopathy after anticoagulant rodenticide ingestion. Patients who developed hypoalbuminemia or elevated alanine aminotransferase level as a result of anticoagulant rodenticide ingestion were also significantly associated with the development of coagulopathy.

Utility of triage shock index in predicting patient outcome in calcium channel blocker poisoning

Introduction:Shock index is defined as heart rate divided by systolic blood pressure. It is reported as a predictor of morbidity and mortality in trauma and acute myocardial infarction in previous studies. It may be valuable in evaluation of calcium channel blocker poisoning. The objective of this study is to examine the probability of serious outcome based on first measured shock index in patients who presented to emergency department with calcium channel blocker poisoning.Methods:A retrospective chart review was conducted on calcium channel blocker poisoning cases in Hong Kong Poison Information Centre from 1 July 2008 to 30 June 2017. Shock index was calculated with blood pressure and pulse measurement at emergency department triage. Odds ratios of various variables for major outcome, mortality, intensive care unit admission, length of stay in acute hospital were calculated by multivariate analysis or negative binomial regression where appropriate. The performance of shock index in predicting major outcome was evaluated with receiver operating characteristic curve.Results:A total of 390 cases were identified, of whom 25.1% developed major outcome and 5.6% died. Shock index showed significant association with major outcome (odds ratio: 17.017, 95% confidence interval: 5.521–52.455). The area under the receiver operating characteristic curve for shock index in predicting major outcome was 0.7008 (95% confidence interval: 0.64–0.76).Conclusion:Higher shock index is associated with worse patient outcome in calcium channel blocker poisoning. However, shock index alone is not reliable in predicting patient outcome. Further research is needed before shock index can be incorporated for use in patient management in poisoning with calcium channel blocker or other anti‐hypertensives.

Poisonings from hydrocarbon inhalant misuse in Australia.

Inhalational misuse of volatile substances has been a significant public health concern because of the risk of sudden death and associated chronic complications such as encephalopathy. The Australian Government released a Consensus-based clinical practice guideline in 2011 on the management of volatile substance use in Australia, which noted a lack of available data particularly on harms. This study aimed to measure (1) the number of calls received by the New South Wales Poisons Information Centre (NSWPIC) regarding inhalational hydrocarbon exposures or poisonings and (2) the number of unintentional deaths reported to the National Coronial Information System (NCIS) in Australia. We performed a retrospective review of all recreational inhalational hydrocarbon exposure calls to the NSWPIC between 1 January 2010 and 31 December 2020. A search was made of the NCIS database in all states and territories over the same period to determine the number of non-intentional inhalational hydrocarbon-related deaths in Australia. Between January 2010 and December 2020, there were 752 primary calls made to the NSWPIC regarding hydrocarbon use or exposure. Age or age bracket was recorded in 748 cases, with 508 (67%) calls involving children or adolescents. Over the same time, there were 58 unintentional deaths involving the recreational use of inhalational hydrocarbons. The median age at death was 23 years (interquartile range = 15-30 years), and 72% (42 cases) were male. Cause of death was predominately acute suffocation/asphyxia, encephalopathy related to chronic use, cardiac arrest likely from sudden sniffing syndrome or thermal injuries secondary to unintentional fires sparked by the volatile agents. Although death and cardiac arrest are uncommon among people in Australia who misuse hydrocarbons for recreational use, the deaths and cardiac arrests tend to occur in adolescents.

Thirteen toxicology tidbits for the emergency clinician.

Emergency Medicine AustralasiaEarly View Trainee Focus Thirteen toxicology tidbits for the emergency clinician Zeff Koutsogiannis MBBS, FACEM, Zeff Koutsogiannis MBBS, FACEM GCertClinTox, Emergency Physician, Clinical Toxicologist Emergency Department, Austin Health, Melbourne, Victoria, Australia Victorian Poisons Information Centre, Austin Health, Melbourne, Victoria, AustraliaSearch for more papers by this authorMarina Guertin MBBS, MPH, DTM&H, Corresponding Author Marina Guertin MBBS, MPH, DTM&H DRANZCOG, Emergency Senior Registrar marina.guertin@gmail.com Emergency Department, Austin Health, Melbourne, Victoria, Australia Correspondence: Dr Marina Guertin, Emergency Department, Austin Health, 145 Studley Road, Heidelberg, VIC 3084, Australia. Email: marina.guertin@gmail.comSearch for more papers by this author Zeff Koutsogiannis MBBS, FACEM, Zeff Koutsogiannis MBBS, FACEM GCertClinTox, Emergency Physician, Clinical Toxicologist Emergency Department, Austin Health, Melbourne, Victoria, Australia Victorian Poisons Information Centre, Austin Health, Melbourne, Victoria, AustraliaSearch for more papers by this authorMarina Guertin MBBS, MPH, DTM&H, Corresponding Author Marina Guertin MBBS, MPH, DTM&H DRANZCOG, Emergency Senior Registrar marina.guertin@gmail.com Emergency Department, Austin Health, Melbourne, Victoria, Australia Correspondence: Dr Marina Guertin, Emergency Department, Austin Health, 145 Studley Road, Heidelberg, VIC 3084, Australia. Email: marina.guertin@gmail.comSearch for more papers by this author First published: 22 February 2023 https://doi.org/10.1111/1742-6723.14190Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Early ViewOnline Version of Record before inclusion in an issue RelatedInformation

Derivation and internal validation of a clinical prediction score to predict major effect or death in acute metamfetamine toxicity

Objective Metamfetamine use can cause serious complications or death. We aimed to derive and internally validate a clinical prediction score to predict major effect or death in acute metamfetamine toxicity. Methods We performed secondary analysis of 1,225 consecutive cases reported from all local public emergency departments to the Hong Kong Poison Information Centre between 1 January 2010 and 31 December 2019. We split the entire dataset chronologically into derivation (first 70% of cases) and validation (the remaining 30% of cases) cohorts. Univariate analysis was conducted, followed by multivariable logistic regression in the derivation cohort to identify independent predictors of major effect or death. We developed a clinical prediction score based on the regression coefficients of the independent predictors in the regression model and compared its discriminatory performance with five existing early warning scores in the validation cohort. Results The MASCOT (Male, Age, Shock, Consciousness, Oxygen, Tachycardia) score was derived based on the six independent predictors: male gender (1 point), age (≥35 years, 1 point), shock (mean arterial pressure <65 mmHg, 3 points), consciousness (Glasgow Coma Scale <13, 2 points), need for supplemental oxygen (1 point), and tachycardia (pulse rate >120 beats/min, 1 point). The score ranges from 0–9, with a higher score indicating higher risk. The area under the receiver operating characteristic curve of the MASCOT score was 0.87 (95% CI 0.81–0.93) in the derivation cohort and 0.91 (95% CI 0.81–1.00) in the validation cohort, with a discriminatory performance comparable with existing scores. Conclusions The MASCOT score enables quick risk stratification in acute metamfetamine toxicity. Further external validation is warranted before wider adoption.

Characterization of Potential Intoxications with Medicines in a Regional Setting.

The Portuguese Poison Information Center (from Portuguese-CIAV) is a call center that offers medical assistance in case of possible intoxication with any kind of product, including medicines. This center´s main goal is to inform and guide the general public and health professionals. This work aimed to analyze and compare data corresponding to the telephone calls from the Algarve region (South of Portugal), received by CIAV during 2019 and 2020, regarding potential intoxications with medicines. To this end, data provided by CIAV on possible cases of medication intoxication in the Algarve region were collected, including the number of calls received, the place of origin of the call, the age group and sex of the intoxicated individual, the route of exposure to the drug, the circumstances of contact with the substance, the existence of symptoms, and the drug or drugs involved in the potential intoxication. The results showed that the number of cases slightly decreased in 2020 (n = 1261) compared with 2019 (n = 1340), with a high number of cases of intoxication in children between one and four years old in both years (21.2%; n = 152 in 2019; 16.4%; n = 115 in 2020). The drugs belonging to the locomotor system group (paracetamol and ibuprofen) were the main drugs involved, followed by the central nervous system pharmacotherapeutic group, namely benzodiazepines (diazepam and alprazolam). Paracetamol was the main drug responsible for the calls to CIAV (n = 71 in 2019; n = 63 in 2020), while for the remaining drugs there were fluctuations in their positions between both years. In some cases, this swinging may be explained by the possible changes in therapy due to potential interactions with drugs used for the treatment of symptoms of COVID-19 or perhaps related to misleading information released by the media about the use of some drugs, such as ibuprofen, during lockdown periods. Although there has been a decrease in calls to report possible drug intoxication in the Algarve region, the profile of calls was very similar. Paracetamol was the drug with the highest number of reported cases and the group of psychotropic drugs showed the largest increase between 2019 and 2020.

A comparison of the accuracy of mushroom identification applications using digital photographs

Objective To compare the accuracy of three popular mushroom identification software applications in identifying mushrooms involved in exposures reported to the Victorian Poisons Information Centre and Royal Botanic Gardens Victoria. Background Over the past 10 years, an increasing number of software applications have been developed for use on smart phones and tablet devices to identify mushrooms. We have observed an increase in poisonings after incorrect identification of poisonous species as edible, using these applications. Design We compared the accuracy of three iPhone™ and Android™ mushroom identification applications: Picture Mushroom (Next Vision Limited©), Mushroom Identificator (Pierre Semedard©), and iNaturalist (iNaturalist, California Academy of Sciences©). Each app was tested independently by three researchers using digital photographs of 78 specimens sent to the Victorian Poisons Information Centre and Royal Botanic Gardens Victoria over a two-year period, 2020–2021. Mushroom identification was confirmed by an expert mycologist. For each app, individual and combined results were compared. Results Picture Mushroom was the most accurate of the three apps and correctly identified 49% (95% CI [0–100]) of specimens, compared with Mushroom Identificator (35% [15–56]) and iNaturalist (35% [0–76]). Picture Mushroom correctly identified 44% of poisonous mushrooms [0–95], compared with Mushroom Identificator (30% [1–58]) and iNaturalist (40% [0–84), but Mushroom Identificator identified more specimens of Amanita phalloides correctly (67%), compared to Picture Mushroom (60%) and iNaturalist (27%). Amanita phalloides was falsely identified, twice by Picture Mushroom and once by iNaturalist. Conclusions Mushroom identification applications may be useful future tools to assist clinical toxicologists and the general public in the accurate identification of mushrooms species but, at present, are not reliable enough to exclude exposure to potentially poisonous mushrooms when used alone.