Single Poison Research Articles

Rapid availability of ethylene glycol test results with enzymatic assay

Background Ethylene glycol poisoning causes metabolic acidosis, organ injury, and death. Ethylene glycol testing is unavailable in many areas. Our laboratory uses an automated glycerol dehydrogenase enzymatic assay to screen for ethylene glycol. We sought to determine how often ethylene glycol results were available within 12 h of the first dose of fomepizole. Methods Records from a single poison center were reviewed from December 2016 to December 2019. Cases were identified by searching for cases that received fomepizole. Outcomes included whether results were available within 12 h, and the turnaround time from time of laboratory order to result. Results Of the 125 cases of suspected toxic alcohol poisoning identified, 73 had screening for ethylene glycol by enzymatic assay. Results were available within 12 h of the initial fomepizole dose in 58 (79%) cases with a median turnaround time of 391 min. Discussion We have demonstrated clinically acceptable turnaround times using an automated screening ethylene glycol assay. The major limitations include lack of approval for this test at this time, the use of voluntarily reported poison center data, and lack of assessment of patient outcomes. Conclusion Enzymatic screening for ethylene glycol yielded results within 12 h in 79% of cases.

GLP-1 Receptor Agonist Exposures Are Increasingly Common and Generally Associated with Mild Symptoms: A Single Poison Center Experience

IntroductionGlucagon-like peptide-1 receptor agonist use has increased over the last decade for glycemic control in type 2 diabetes mellitus, cardiovascular risk reduction, and weight loss. Clinical trials indicate that gastrointestinal adverse effects are commonly experienced and severe hypoglycemia is rare; however, there is little data regarding glucagon-like peptide-1 receptor agonist in overdose.MethodsWe performed a retrospective chart review evaluating and characterizing glucagon-like peptide-1 receptor agonist exposures reported to a single poison center between 2006 and 2023. Patient demographics, circumstances of exposure, clinical effects, and outcomes were abstracted from charts. Descriptive statistics were utilized to summarize demographic information and clinical factor data.ResultsA total of 152 charts met inclusion criteria. Therapeutic errors accounted for 91% of exposures. Most patients (67%) reported no symptoms, although not all patients were followed to a definitive outcome. Nausea, vomiting, generalized weakness, and abdominal pain were the predominant symptoms reported. Most patients (62%) were monitored and closely followed in the home setting. Hypoglycemia was rare but occurred in the setting of a single agent glucagon-like peptide-1 receptor agonist exposure in two patients. Two additional patients who developed hypoglycemia involved co-administration of insulin. 21% of the exposures were related to errors on initial use of the pen.ConclusionExposures to glucagon-like peptide-1 receptor agonist have increased substantially over the years. Effects from an exposure tended to be mild and primarily involve gastrointestinal symptoms. Hypoglycemia was rare. Therapeutic and administration errors were common. Education on pen administration may help to reduce errors.

Cypermethrin and/or sulfamethoxazole exposure effect on apoptosis and endoplasmic reticulum of grass carp cardiomyocyte

With the soar use range of pesticides and antibiotics in agricultural production, the pollution of surrounding runoff has become more severe; thus, the health and safety of non-target species such as fish are at risk. Excessive amounts of cypermethrin (CMN, 0.651 mg/l) and sulfamethoxazole (SMZ, 0.3 mg/l) are known to trigger oxidative stress and endoplasmic reticulum stress, resulting in toxic effects on cells. The damage degree of poisons on grass carp and the effect of the corresponding axis pathway PERK/eif2α/CHOP are still unknown. Therefore, our study set up two single poison groups (CMN/SMZ) and a combined poison group (CMN&SMZ) to detect this pathway and related indicators. After detection, the content of MDA both in CMN and SMZ group myocardium tissue was increased, while the SOD, CAT activity and GSH levels were decreased. Apoptosis-related genes (Bax, PUMA, P53 and Caspase-3/9), inflammation-related genes (TNF-α, iNOS and IL-1β/6/8), ER stress pathway PERK/eif2α/CHOP and related genes (ATF6, IRE1a and GRP78) were all increased; in contrast, the anti-apoptotic gene Bcl-2 was down-regulated. From the overall trend observation, the apoptosis proportion of cardiomyocytes in the combined poison group was higher than that of the single poison. In summary, this study shows that CMZ and SMZ can induce oxidative stress and subsequent ER stress in grass carp cardiomyocytes by regulating the PERK/eif2α/CHOP signaling axle, thereby inducing apoptosis, and followed by inflammatory responses. The combined effect of the CMZ and SMZ mixture was severer than that of a single poison (CMZ or SMZ), so it can be inferred that the damage degree of grass carp myocardium tissue would be aggravated with the appearance of CMZ or/and SMZ. The experimental results of this study have suggestions and warnings for the toxicological research of CMZ and SMZ and the management of industrial and ecological balance.

Home management of pediatric sulfonylurea ingestions

Introduction Sulfonylureas are oral antidiabetic medications that act by stimulating insulin release from pancreatic beta cells. Unintentional pediatric ingestions may result in hypoglycemia. While guidelines often recommend up to a 24-hour hospital observation period for any ingestion, the Oregon Poison Center has historically managed select patients at home. This study aimed to describe outcomes of home-managed pediatric sulfonylurea exposures and characteristics of ingestions that are appropriate for home monitoring. Methods This is a retrospective chart review of pediatric (≤5 years) sulfonylurea ingestions in a single poison center over a 19-year period (2002–2020). We reviewed 491 individual cases for age, ingestion quantity, witnessed or unwitnessed ingestions, hypoglycemia (<60 mg/dL), disposition, and severe events (seizures or coma). We excluded cases in which missing pills were later found or another agent was identified. Results Of 474 patients meeting inclusion criteria, 135 (28%) were initially managed at home. Of these, 115 (85.3%) were ingestions of ≤1 tablet, where 68 (59%) were witnessed and 47 (41%) were unwitnessed. One hundred twenty five (92.6%) of these patients were successfully monitored at home, with 10 (7%) ultimately referred to a healthcare facility (HCF). Symptoms of hypoglycemia, measured glucose on home meter <60 mg/dL, fluctuations in monitored glucose, or parental concern were indications for HCF referral. Of those referred, 5 (4%) developed uncomplicated, asymptomatic hypoglycemia. Two of these received octreotide, at the discretion of the treating physician. No patients developed seizures or coma. Discussion We report 135 pediatric sulfonylurea ingestions managed with initial home monitoring, the majority of which were successfully monitored at home without any reported adverse events. Ten patients “failed home monitoring,” as defined by referral to a healthcare facility. Of these, five developed hypoglycemia, though no patients developed symptoms or serious adverse events. Conclusion Our findings support home observation for children ≤5 years with small ingestions of second-generation sulfonylureas.

Synergistic poisoning of KCl and PbCl2 on commercial V2O5-MoO3/TiO2 catalysts for MSW incineration flue gas denitrification

Alkali and heavy metal chlorides cause the deactivation of selective catalytic reduction (SCR) catalysts during municipal solid waste incineration. In this study, the synergistic poisoning of KCl and PbCl2 on commercial V2O5-MoO3/TiO2 SCR catalysts was investigated. Compared with KCl, PbCl2 could combine with Mo components and protect V sites from poisoning. Besides, the chemical bonds between PbCl2 and V sites were weaker. Hence, the single poisoning of PbCl2 was weak to the denitrification of SCR catalyst. Whereas, under the co-poisoning of KCl and PbCl2, V-O-Cl structures were formed, which suppressed NH3 activation, thereby causing the deactivation of SCR catalyst.

Vasodilation in patients with calcium channel blocker poisoning treated with high-dose insulin: a comparison of amlodipine versus non-dihydropyridines

Background: High dose insulin (HDI), an inotrope and vasodilator, is a standard therapy for calcium channel blocker (CCB) poisoning. HDI causes vasodilation by stimulating endothelial nitric oxide synthase (eNOS). Most literature supporting HDI for CCB poisoning involves verapamil toxicity; however, amlodipine now causes more CCB poisonings. Unlike other CCBs, amlodipine stimulates eNOS and may cause synergistic vasodilation with HDI. The purpose of this study was to determine if amlodipine-poisoned patients treated with HDI had more evidence of vasodilation than similarly treated patients with non-dihydropyridine (non-DHP) poisoning. Methods: This was a retrospective study from a single poison center. Cases were identified via the generic code “Calcium Antagonists” in which the therapy “High Dose Insulin/Glucose” was “performed, whether or not recommended” from 2019–2021. Evidence of vasodilation was assessed via maximum number of vasopressor infusions per case, vasopressor doses, and use of rescue methylene blue to treat refractory vasoplegia. Results: Thirty-three patients were enrolled: 18 poisoned with amlodipine, 15 with non-DHPs (verapamil n = 10, diltiazem n = 5). The median number of maximum concomitant vasopressors in the amlodipine group was 3 (IQR: 2–5; range 0–6) and 2 in the non-DHP group (IQR: 1–3; range 0–5; p = 0.04); median difference in maximum concomitant vasopressors between groups was 1 (95% confidence interval: 0–2). Median maximum epinephrine dosing was higher in the amlodipine group (0.31 mcg/kg/min) compared to non-DHPs (0.09 mcg/kg/min; p = 0.03). Use of rescue methylene blue was more common in the amlodipine group (7/18 [39%]) than in the non-DHP group (0; p = 0.009). Conclusions: Amlodipine poisoned patients treated with HDI required more vasopressors, higher doses of epinephrine, and more often received rescue methylene blue than similarly treated patients with verapamil or diltiazem poisoning. These differences suggest amlodipine-poisoned patients had more evidence of vasodilation. Further study is warranted to determine if synergistic vasodilation occurs when HDI is used to treat amlodipine poisoning.

Compliance to whole bowel irrigation recommendations: a single poison center study

Introduction: Whole Bowel Irrigation (WBI) is used as a method of gastrointestinal decontamination for poisoned patients and may have low compliance when recommended by poison centers (PC). We set out to determine WBI compliance and analyze trends and possible associations between WBI compliance and clinical outcomes. Methods: We conducted a single-center retrospective chart review of PC data from 1/1/2011 to 12/31/2019 and included cases in which WBI was recommended. We collected demographic data, exposure history, therapies recommended and performed, and clinical outcomes. Compliance rate was calculated. Chi-squared and Mann-Whitney U tests were performed to look for differences in compliance based on case characteristics such as compliance rate by year, compliance based medication ingested and presence of intubation. We also looked for a possible association between WBI compliance and clinical outcome. Results: Four hundred and eighty-three cases met inclusion criteria. Fifty-five percent of patients were male and the median age was 32.5 years. Compliance to WBI recommendations was 58.2%. There was no significant difference in compliance when comparing by age, gender, medication ingested, or year. There was no association between compliance to WBI and clinical outcomes. Conclusions: We calculated a compliance rate of 58% when WBI was recommended. Compliance to WBI does not appear to be associated with changes in clinical outcome.

The Timing of Clinical Effects of Bupropion Misuse Via Insufflation Reported to a Regional Poison Center.

Bupropion is an antidepressant medication with expanding indications including smoking cessation, weight loss, attention-deficit/hyperactivity disorder, seasonal affective disorder, and amphetamine dependence. Despite its increasing popularity among providers, it has a well-known narrow therapeutic window that can lead to delayed onset of symptoms with extended-release formulations and devastating consequences in overdose. We have noticed some patients misusing bupropion via insufflation, which added a layer of complexity with regards to the therapeutic application of the drug. This route of use created difficult decisions regarding clinical monitoring in these patients. To determine if prolonged observation is required after insufflation of bupropion and to further describe effects from this route of use. This is a retrospective observational study reviewing all the cases of insufflated bupropion use reported to a single poison center without any other coingestants. The majority (85.7%) of patients had mild or moderate effects, and seizures occurred in 19.6% of cases; and the vast majority of patients were symptomatic by the time of the initial call to the poison center. We did not encounter any delayed effects after this route of use. This report describes the clinical effects reported, and the timing of these effects, after insufflation of bupropion.

Initial Experience with F(ab’)2 Antivenom Compared with Fab Antivenom for Rattlesnake Envenomations Reported to a single poison center during 2019

There are two Food and Drug Administration (FDA)-approved antivenoms available for rattlesnake envenomations in the United States: the equine-derived F (ab')2 product sold with the brand name Anavip (F (ab')2AV) and the ovine-derived Fab product sold with the brand name Crofab (FabAV). To compare the clinical outcomes of rattlesnake envenomation patients treated either with FabAV or F (ab')2AV or a combination of these. This is a retrospective chart review of all human rattlesnake envenomations requiring antivenom reported to one regional poison control center in 2019. Patients were categorized as receiving F (ab')2AV, FabAV, or a combination of both. Baseline characteristics included demographics, time between envenomation and administering antivenom, an abbreviated snakebite severity score (ASSS), and the presence of coagulopathy at presentation. There were a total of 123 patients requiring antivenom. Of these, 57 (46.3%) received FabAV, 53 (43.1%) received F (ab')2AV, and 13 (10.6%) received a combination of these. Those receiving F (ab')2AV were younger, with an average age of 40.8 (±25.0) years versus 51.3 (±19.9) years (p=0.0161) for those receiving FabAV. Time between envenomation and antivenom administration, ASSS, and the percentage of those with coagulopathy at presentation were otherwise similar. Patients treated with F (ab')2AV or FabAV received a similar total number of vials [16.0 vials (±6.1) vs 14.5 vials (±5.4), p=0.189], but patients treated with F (ab')2AV were more frequently given additional doses [31 patients (58.5%) vs. 22 FabAV patients (38.6%), p=0.0051]. In patients with outpatient follow-up for 2 weeks, fewer patients treated with F (ab')2AV developed late coagulopathy [5 patients (11.1%) vs 22 FabAV patients (48.9%), p=0.0004]. Adverse events were generally mild and uncommon with no difference in frequency between patients who received either antivenom (2F (ab')2AV patients vs 4 FabAV patients, p=0.6637). Other than patient age, we found no significant difference in the baseline demographics, time between envenomation and administering antivenom, an abbreviated snakebite severity score (ASSS), and the presence of coagulopathy at presentation between patients receiving F (ab')2AV or FabAV. Patients receiving F (ab')2AV were more likely to be given an additional dose beyond the minimum typical treatment course, but less likely to develop late coagulopathy. Adverse events were uncommon and generally mild whether patients received either antivenom.

Cyclosporine as a novel treatment for amatoxin-containing mushroom poisoning: a case series

Ingestion of amatoxin-containing mushrooms can lead to fulminant hepatotoxicity and death. Despite recent interest in therapeutic options for amatoxin-exposed patients, there is no single, recommended treatment for amatoxin poisoning. Alpha-amanitin, the principal toxin in amatoxin-containing mushrooms, requires entry into hepatocytes via organic anion transporting polypeptide (OATP) 1B3 before the cascade of cellular events occurs leading to hepatocyte necrosis, liver failure, and in severe cases liver transplantation or death. Three patients managed through a single poison centre with confirmed amatoxin-containing mushrooms ingestions were treated with intravenous cyclosporine, a known potent OATP1B3 inhibitor, along with supportive care. All patients presented with classic delayed symptoms of nausea, vomiting and diarrhea. No patient progressed to fulminant hepatic failure, although two patients developed a transient rise in liver transaminases. All recovered and were discharged from hospital. No patient had an adverse effect from cyclosporine. In addition, we performed an in-vitro study of the role of cyclosporine in cultured HEK293T cells and human hepatoma Huh7 cells. Cyclosporine effectively inhibited OATP1B3-mediated uptake of alpha-amanitin, and improved cell viability of alpha-amanitin exposed cultured Huh7 cells. We conclude that IV cyclosporine, a drug readily available in most hospitals, may be useful to reduce hepatotoxicity from amatoxin poisoning.

In cold blood: Observational descriptive review of Eastern Massasauga rattlesnake bites reported to a single poison center over time

The Eastern Massasauga rattlesnake (Sistrurus catenatus catenatus) is a pit viper indigenous to the Great Lakes region and the only venomous snake native to Michigan. It is small-to-medium, thick-bodied with dark brown, bow-tie shaped blotches. Its behavior is described as reclusive and docile and it prefers damp habitats. The venom of the Eastern Massasauga is primarily cytotoxic and hemotoxic. Previous literature describes severe coagulopathies following Eastern Massasauga envenomings, with some resulting in death. The objective of this study was to characterize Eastern Massasauga envenomings in humans reported to the Michigan Poison & Drug Information Center from 2003 to 2020, including a description of clinical manifestations, incidence and characterization of coagulopathies, and medical outcome severities. This was a retrospective review of Eastern Massasauga snakebites reported to our state poison center over time. Coagulopathies were classified according to previous toxicological snakebite literature. The degree of envenoming was scored using an institutional guideline, representing a modified version of validated snakebite severity score system. Our longitudinal review demonstrated Eastern Massasauga bites led to clinically significant toxicity, including persistent, recurrent, and late coagulopathies, though with low incidence of bleeding events. Cases typically resolved with use of antivenom. This, to our knowledge, is the largest descriptive case series characterizing Eastern Massasauga snakebites.

Exposures in pregnant patients reported to United States Poison Centers

Background Limited data describe poisoning exposures in pregnant women. Previous studies are limited to inpatient populations, those seen only by toxicologists, or single poison centers. This study aimed to describe poison exposures reported to U.S. poison control centers in pregnant patients compared to non-pregnant controls. Methods This was a retrospective observational study of exposures reported to the American Association of Poison Control Centers National Poison Data System from 2000 through 2019. Pregnant patients were included from 15–44 years along with a random sampling of 5:1 age and year matched control group of non-pregnant exposures. Demographics, primary substance, and known medical outcomes were described. Chi square analysis was performed for comparisons. Results From 2000 to 2019, a total of 131,619 pregnant cases and 658,095 non-pregnant controls were identified. The median age was 27 years (IQR: 22, 31) for the matched groups. For known trimester of pregnancy: 29.8, 37.0, and 28.2% were in the first, second, and third trimester, respectively. Most common exposures were analgesics and cleaning products. Intentional exposures were more common in non-pregnant compared to pregnant cases (41.2 vs 21.9%; OR 2.71, 95% CI 2.67–2.75), mostly self-harm attempts (31.5 vs. 15.8%). Notably, there was a large discrepancy in the proportion of environmental exposures, with fewer in non-pregnant controls compared with pregnant cases (3.8 vs. 12.1%; OR 0.29, 95% CI 0.28–0.29). More non-pregnant cases had multiple substance exposures compared with pregnant cases (22.2 vs. 10.9%; OR 2.34, 95% CI 2.29–2.38). There were more moderate effect outcomes in non-pregnant compared with pregnant cases (13.2 vs. 6.3%; OR 2.25, 95% CI 2.20–2.30). Conclusions Outcomes of poisoning exposures in pregnant patients reported to U.S. poison centers are less serious compared to non-pregnant controls, likely due to the lower rates of intentional abuse and self-harm exposures and greater number of minimally toxic environmental exposures.

Poisoning among the elderly

ObjectivesPoisonings continue to be an important public health problem. Herein, we analyzed the epidemiology of poisonings in elderly individuals. MethodsRetrospective cohort study conducted between 2011 and 2019 in a university hospital. We analyzed demographic variables, type of poison involved, suicidal or accidental nature of the poisoning, and the probability of admission, or death to the hospital. ResultsA total of 880 (6.1%) of the 14,300 poisonings treated in the same period occurred in people over 65 years of age. The most numerous group were individuals between 65–69 years-old (39%), followed by the group of 70–75 years-old (20%), being men 57%. In 88% of the cases a single poison participated, being by frequency alcohol (51.6%), drugs (29.5%), and household or industrial products (12.8%). Alcohol intoxication predominated in men up to 75 years of age, and above this age drug or suicidal intoxication predominated, mainly in women. A total of 145 (16%) subjects were hospitalized, the drugs most frequently implicated being digoxin and benzodiazepines. The probability of hospital admission was associated with intoxication by metformin, digoxin, lithium or with the age of the patient (OR per year = 1.03; 95% CI: 1.0–1.06). A total of 19 patients died (2.16%), mainly due to suicidal caustic ingestion (OR = 5.7: 95% CI: 1.4–23.6) or by drugs, directly related to metformin (OR = 10.1; 95% CI: 2.4–42.4). ConclusionsThe prevalence of poisoning in the elderly is not negligible, and physicians should have a high index of suspicion in a complex situation.

Characterization of Pt-based oxidation catalyst – Deactivated simultaneously by sulfur and phosphorus

Simultaneous poisoning of sulfur + phosphorus on a platinum-based diesel oxidation catalyst was studied to gain a deeper understanding on the catalyst deactivation. Compared to a single poisoning (sulfur or phosphorus), the simultaneous poisoning had a severe effect on the catalyst activation: light-off temperature for 90% conversion of propene was not reached, this of carbon monoxide was much higher than expected, and the maximum conversion of nitrogen monoxide collapsed. With very comprehensive structural characterization by various methods (e.g. STEM-EDS, XPS, DRIFTS) used, we achieved to conclude an explanation for this. In the case of the S + P-poisoning of the catalyst, formed aluminum phosphate was found to block adsorption sites for sulfur species on alumina and sulfur adsorbs mainly on cerium oxides. In addition, sulfur species remain with and in the vicinity of the platinum particles blocking active sites.

Clinical effects of intravenous bupropion misuse reported to a regional poison center.

Bupropion is an antidepressant medication with expanding indications including smoking cessation, weight loss, attention-deficit/hyperactivity disorder, seasonal affective disorder, and amphetamine dependence. Despite its increasing popularity among providers, it has a well-known narrow therapeutic window which can lead to delayed onset of symptoms with extended-release formulations and devastating consequences in overdose. We have noticed some patients misusing bupropion via intravenous use and had difficulty guiding decisions regarding clinical monitoring in these patients. As this route entirely changes the kinetics of bupropion, this has caused concern within our group. We reviewed all the cases of intravenous bupropion use reported to a single poison center without any other coingestants. The majority (66.7%) of patients had moderate effects and one patient had a seizure. No deaths were reported. All patients were symptomatic by the time of initial call to the poison center if they had any reported symptoms due to bupropion. This case series describes the clinical effects reported, and the timing of these effects, after intravenous bupropion use.

A typical case of syphilitic spinal cord injury

There is not a single poison, not a single infection that would produce such a variety of changes in the body as syphilis. Not a single organ is guaranteed against this terrible scourge of modern humanity. More syphilis does not spare the central nervous system, which, thanks to the modern conditions of life, is a locus mi-noris resistentiae. Damaging this organ, it produces an extremely variegated picture of both pathological and anatomical changes and clinical manifestations and course, depending on the diversity of the nature of the process, very different localization, speed or slowness of development.

Intoxicaciones en la tercera edad

ObjectivesPoisonings continue to be an important public health problem. Herein, we analyzed the epidemiology of poisonings in elderly individuals. MethodsRetrospective cohort study conducted between 2011 and 2019 in a university hospital. We analyzed demographic variables, type of poison involved, suicidal or accidental nature of the poisoning, and the probability of admission, or death to the hospital. ResultsA total of 880 (6.1%) of the 14,300 poisonings treated in the same period occurred in people over 65 years of age. The most numerous group were individuals between 65-69 years-old (39%), followed by the group of 70-75 years-old (20%), being men 57%. In 88% of the cases a single poison participated, being by frequency alcohol (51.6%), drugs (29.5%), and household or industrial products (12.8%). Alcohol intoxication predominated in men up to 75 years of age, and above this age drug or suicidal intoxication predominated, mainly in women. A total of 145 (16%) subjects were hospitalized, the drugs most frequently implicated being digoxin and benzodiazepines. The probability of hospital admission was associated with intoxication by metformin, digoxin, lithium or with the age of the patient (OR per year = 1.03; 95% CI: 1.0-1.06). A total of 19 patients died (2.16%), mainly due to suicidal caustic ingestion (OR = 5.7: 95% CI: 1.4-23.6) or by drugs, directly related to metformin (OR = 10.1; 95% CI: 2.4-42.4). ConclusionsThe prevalence of poisoning in the elderly is not negligible, and physicians should have a high index of suspicion in a complex situation.

Synergistic effect of arsenic and different potassium species on V2O5-WO3/TiO2 catalyst poisoning: Comparison of Cl−, SO42− and NO3− anions

Arsenic and potassium species were considered as the major poisons for V2O5-WO3/TiO2 catalyst deactivation. However, their synergistic impacts were rarely reported and the role of anions (Cl−, SO42− and NO3−) were ignored. Therefore, a series of work were conducted in this research. Results indicated that the co-effect of (As+K) was more serious than the additive effect of single poison. Both physical and chemical properties changes were responsible for this phenomenon. Except for the negative effect of As2O3 and K cation, different anions also presented different impacts on catalyst redox ability and ammonia adsorption capacity, which further inhibited NH3-SCR reactions.

Current fatality rate of suspected cyclopeptide mushroom poisoning in the United States

Objective This study was designed to determine the fatality rate of suspected cyclopeptide-containing mushroom ingestions reported to the National Poison Data System (NPDS). Background Although silibinin reportedly improves survival in suspected cyclopeptide-containing mushroom ingestions, the greater than 20% untreated fatality rate that is often cited is based on decades-old data. An ongoing open-label silibinin trial will likely use historical cases as comparators. A recent single poison control center (PCC) study showed a fatality rate of 8.3%. This study was designed to validate those findings in the NPDS. Methods This study was an 11-year (1/1/2008-12/31/2018) retrospective review of suspected cyclopeptide-containing mushroom ingestions reported to NPDS. Inclusion and exclusion criteria were the same as the ongoing silibinin trial: Age >2-years-old; history of eating foraged mushrooms; gastrointestinal symptoms within 48 h of mushroom ingestion; and aminotransferases above the upper limit of normal within 48 h after ingestion. Each original participating PCC confirmed eligibility, diagnosis, treatment, and outcome on included cases. Results During the study period, 8,953 mushroom exposures were reported to NPDS, of which 296 met inclusion criteria. The PCC survey response rate was 60% (28/47 PCCs), and the individual case response rate was 59% (174/296). Twenty-six cases were subsequently excluded leaving 148 included cases. The overall mortality rate was 8.8% (13/148). Mortality in silibinin/silymarin-treated vs untreated cases was 9.5% (4/42), vs 8.5% (9/106), respectively. A mycologist identified mushrooms in 16.9% of cases (25/148), of which 80% (20/25) were cyclopeptide-containing. Among these confirmed cases, the mortality rate was 10% (1/10) in both silibinin/silymarin-treated and untreated cases. Conclusions The contemporary mortality rate of patients with presumed cyclopeptide-mushroom poisoning is only 8.8%. This likely represents improved supportive care for patients with acute liver injury and should be considered the current standard for historical controls in the United States.

The seasonality of suicide attempts: a single poison control center perspective

Introduction: Suicide attempts by poisoning are increasing and suicide occurrence may be associated with seasonality. We performed a retrospective analysis of poisoning exposure data from a single Poison Control Center (PCC) to determine if suicide attempts were associated with season, day of the week, and/or US holidays.Methods: We analyzed exposure cases identified as “intentional overdose - suspected suicide attempt” over 2009–2012. We used singular spectrum analysis (SSA) to detect cyclic patterns in the data and then performed Poisson regression and t-tests to determine if the number of cases were associated with season, day of the week, and US holidays.Results: There were 42,578 cases of “intentional overdose – suspected suicide” during the study period. Singular Spectrum Analysis (SSA) showed that the number of cases associated with poisoning suicide attempts peaked in the Spring and dipped in the Fall. Regression analysis showed higher numbers of suspected suicide attempts from intentional overdose in spring compared with winter by 1.07 times (p = 0.003), and on Sunday (p < 0.001), Monday (p < 0.001), and Thursday (p = 0.02) compared with Saturday by at least 1.09 times. No significant difference was seen for most holidays except for lower numbers of cases around Christmas (3 days before and after; 22.0 vs. 32.3 on control dates, p < 0.001).Conclusions: Suicide attempts by poisoning are associated with season of the year and some days of the week. Further research is required determine reasons for these associations and implementation of public health interventions.