Clinical Toxicology最新文献

Introduction: Tarantulas of the Poecilotheria genus are medically important arthropods in Sri Lanka and are also found in India. This study aimed to describe the epidemiological and clinical features of tarantula bites in Sri Lanka.

Methods: We conducted a prospective observational study of patients with tarantula bites over 3.5 years in the medical and paediatric wards at two hospitals in Sri Lanka starting in February 2021. Data were collected using an interviewer-administered questionnaire.

Results: There were 17 patients with tarantula bites of whom 15 were adults and two were children. The median age of adults was 47 years (range 26-62 years). Most were males (12/17) and were bitten in the daytime (14/17), in small jungles (8/17), and on their feet (8/17). Most (11/17) were admitted to the medical facility within 1 h of the bite. Sixteen of 17 patients developed local envenoming features including local pain in 15, local swelling in 13, erythema at the site of the bite in five, and itching in four. Three of 17 had generalized muscle pain and four were found to have painful muscle cramps.

Conclusion: Tarantula bites from the Poecilotheria genus frequently cause local envenoming effects but few patients develop muscle pain and painful muscle cramps.

Introduction: Snakebite envenoming is a multidimensional issue that causes severe functional and life-challenging consequences among rural communities in tropical countries. Current research and treatments are largely focused on the acute effects of envenomation and short-term health outcomes. The knowledge of snakebite-induced long-term consequences is highly limited.

Case series: We report the development of squamous cell carcinoma at the bite site several years later in four patients who are suspected to have been bitten by cobras (Naja naja). Following bites, the victims presented typical symptoms of cobra envenomings including ptosis, altered sensorium, and breathing difficulties. However, difficult-to-heal wounds were a chronic health sequelae with frequent desquamation cycles which led to squamous cell carcinoma. Surgery as the primary therapeutic approach was used for all patients to address this issue.

Discussion: These patients highlight the importance of squamous cell carcinoma in previously damaged tissue from snakebites as a possible long-term consequence. This emphasises the need for surveillance systems focused on a broad range of snakebite-induced consequences including long-term pathological, psychological, and socioeconomic conditions.

Conclusion: This case series describes pathological complications following cobra bites that require further research to determine mechanistic and epidemiological insights in the most affected regions by snakebites, specifically in India.

Introduction: Glucagon-like peptide-1 agonists have gained attention in recent years due to their efficacy in managing type II diabetes mellitus and their emerging role in weight management. The purpose of this study was to characterize glucagon-like peptide-1 agonist exposures reported to a single United States regional poison center over nine years, including causes of exposure, associated clinical effects, and potential areas for improving patient education and safety.

Methods: This retrospective cohort study analyzed all poison center calls involving glucagon-like peptide-1 agonists submitted to a single United States regional poison center from 14 January 2014 to 1 May 2023. Data were abstracted from the electronic medical record of the poison center, including demographics, call volume, drug involved, type of exposure, frequency of hypoglycemia, and other side effects.

Results: Two hundred and thirty-seven cases involving glucagon-like peptide-1 agonists were reported to the poison center. The annual number of cases increased sharply over this period. Most patients (n = 166, 70.0%) were females. Most calls (n = 164, 69.2%) were due to unintentional therapeutic errors. Semaglutide was the most frequently involved medication (n = 72, 36.0%). Hypoglycemia was identified in eight patients (3.4%). The lowest mean (±SD) blood glucose concentration in these hypoglycemic patients was 49.6 ± 23.7 mg/dL (2.76 ± 1.3 mmol/L).

Discussion: Unintentional therapeutic errors were involved in 164 (69.2%) cases. Despite the generally mild clinical effects observed in this study, the occurrence of hypoglycemia in a subset of patients, often requiring hospitalization, is of concern. With reports of the acquisition of these medications through online platforms and poorly regulated compounding sources, this trend may pose public health risks.

Conclusions: This study demonstrates the increasing incidence of glucagon-like peptide-1 agonist exposures reported to a United States regional poison center, predominantly due to unintentional overdoses, which highlights the need for ongoing patient education.

Introduction: Sodium nitrite is a potent oxidizer, which may precipitate rapidly lethal methemoglobinemia. Prompt diagnosis and treatment may salvage otherwise fatal cases. It is unclear if emergency departments are prepared for increasing cases. We describe the availability and geographic distribution of real-time methemoglobin testing and methylthioninium chloride (methylene blue) availability in three contiguous United States.

Methods: This is a cross-sectional survey of hospitals served by a regional poison center in the Upper Midwestern United States. Hospitals were identified by cross-referencing poison center, health department, and state trauma databases. We queried methemoglobin testing capabilities of each site as well as immediate methylthioninium chloride availability. Resulting data are described with descriptive statistics, and predictors of testing and treatment availability are evaluated in multivariable logistic regression.

Results: We identified 320 hospitals with emergency care, analyzing 228 (71.3%) after exclusions. Real-time methemoglobin testing was available at 56 sites (30.6% of 183 respondents). Of hospitals describing methylthioninium chloride availability, 59.4% (130/219) reported having it on-site. A significant difference in real-time methemoglobin testing existed across largest and smallest population strata in adjusted analysis (OR: 64.6: 95% CI: 4.1-1,037). Similarly disparate availability of methylthioninium chloride was observed. Spatial distribution of methemoglobin testing and methylthioninium chloride availability demonstrated notable urban-rural disparities.

Discussion: These data demonstrate a wide disparity in the availability of real-time methemoglobin testing and methylthioninium chloride availability, suggesting that the region is ill-prepared to care for severe methemoglobinemia. Our analysis points to a disconnect between our current poison center recommendations and the capacities of our consulting institutions.

Conclusions: We demonstrate urban-rural disparities in diagnostic and therapeutic capacity for the management of acute methemoglobinemia in this region, as well as significant geographic variations in methylthioninium chloride stocking and poisoning preparedness. Poison centers must therefore maintain an awareness of antidote availability for this emerging toxicological emergency.

Introduction: Delayed neurological sequelae is a common complication following carbon monoxide poisoning, which significantly affects the quality of life of patients with the condition. We aimed to develop a machine learning-based prediction model to predict the frequency of delayed neurological sequelae in patients with carbon monoxide poisoning.

Methods: A single-center retrospective analysis was conducted in an emergency department from January 01, 2018, to December 31, 2023. We analyzed data from patients with carbon monoxide poisoning, which were divided into training and test sets. We developed and evaluated sixteen machine learning models, using accuracy, sensitivity, specificity, and other relevant metrics. Threshold adjustments were performed to determine the most accurate model for predicting patients with carbon monoxide poisoning at risk of delayed neurological sequelae.

Results: A total of 360 patients with carbon monoxide poisoning were investigated in the present study, of whom 103 (28.6%) were diagnosed with delayed neurological sequelae, and two (0.6%) died. After threshold adjustment, the synthetic minority oversampling technique-random forest model demonstrated superior performance with an area under the receiver operating characteristic curve of 0.89 and an accuracy of 0.83. The sensitivity and specificity of the model were 0.9 and 0.8, respectively.

Discussion: The study developed a machine learning-based synthetic minority oversampling technique-random forest model to predict delayed neurological sequelae in patients with carbon monoxide poisoning, achieving an area under the receiver operating characteristic curve of 0.89. This technique was used to handle class imbalance, and shapley additive explanations analysis helped explain the model predictions, highlighting important factors such as the Glasgow Coma Scale, hyperbaric oxygen therapy, kidney function, immune response, liver function, and blood clotting.

Conclusions: The machine learning-based synthetic minority oversampling technique-random forest model developed in this study effectively identifies patients with carbon monoxide poisoning at high risk for delayed neurological sequelae.

Background: Overdose is frequently categorized dichotomously: an inadvertent therapeutic or recreational misadventure versus a deliberate overdose for self-injurious or suicidal purposes. Categorizing overdoses based on this dichotomy of intention is fraught with methodological problems and may result in potentially inappropriate and/or divergent care pathways.

Overdose-related intent lies along a continuum: Suicidality can rapidly shift in magnitude and frequency at different points in time. A patient's overdose may reflect varying degrees of desire to die, ambivalence about living, disregard for risk, or pleasure-seeking. Careful assessment of overdose-related cognitions is warranted in all overdose patients.

The clinical interview is key to understanding an overdose: There is an irreducibly subjective character to an overdose such that a collaborative understanding of an overdose episode can only be discovered by spending time in dialogue with the patient. At the same time, the objective risk factors for and circumstances of the overdose need to be integrated with the subjective experience for a comprehensive prevention approach.

There can be several motivations underlying an overdose: Some overdoses might be wholly inadvertent or simply impulsive. However, if there is some degree of intent present, then the patient who overdosed has attempted to communicate something by means of that overdose, and this message might include something other than the desire to die.

Attending to both the subjective and objective perspectives of an overdose can assist in identifying modifiable risk factors: Overdose-related intent and motivation may be targeted with treatment plans to reduce elevated risk states. Some patient-specific overdose risk factors are modifiable, such as managing mental health and other psychosocial issues, reducing access to lethal means, and promoting safe prescribing and medication administration practices. Other risk factors are either unmodifiable (e.g., personal history of overdose) or involve public health systems.

Conclusions: Overdose-whether involving medications, illicit substances, hazardous chemicals, or otherwise-can be conceptualized as a single behavioral episode with variable intentionality, personal motivations, and risk factors. Clinical/medical toxicologists are uniquely positioned to contribute to personalized risk reduction post-overdose.

Introduction: Nitric and hydrofluoric acids are commonly used in the commercial cleaning industry. We are unaware of reports of nitric acid inhalation forming methaemoglobin. Additionally, methaemoglobinaemia and treatment with methylthioninium chloride (methylene blue) may precipitate clinical uncertainty due to similar wavelengths of absorbance in pulse oximetry.

Cases: We report two patients with respiratory distress from symptomatic methaemoglobinaemia following a prolonged, inhaled occupational exposure to nitric acid in the context of industrial cleaning. Their methaemoglobinaemia was successfully treated with methylthioninium chloride, per remote toxicology advice. However transient oxygen desaturation as reported by pulse oximetry resulted in concern from the treating team.

Discussion: The liberation of oxides of nitrogen from nitric acid bypasses the upper airway without irritation and dissolves in the mucoid lower respiratory tract, oxidising haemoglobin to methaemoglobin. Prolonged undetected exposure with filter saturation, and impaired ventilation is the proposed cause of methaemoglobinaemia in the cases presented. Additionally, methylthioninium chloride absorbs light at the 660 nm wavelength interfering with pulse oximeter interpretation, precipitating the appearance of rapid, severe oxygen desaturation.

Conclusion: Lack of upper airway irritation can lead to unrecognised prolonged nitric acid fume exposure causing methaemoglobinaemia. Remote toxicology advice should include pulse oximeter interference expectations in the presence of methaemoglobinaemia and when administering methylthioninium chloride.

Introduction: Quetiapine shares sodium channel-blocking properties with tricyclic antidepressants. We present the electrographic findings in two patients with severe quetiapine poisoning.

Case summaries: Two patients poisoned with quetiapine presented with impaired consciousness, requiring mechanical ventilation and vasopressor support, with one also experiencing status epilepticus. Their peak serum quetiapine concentrations were 4.52 mg/L and 25.6 mg/L.

Images: On admission, electrocardiograms for both patients revealed a tall R wave in lead aVR, deep S wave in lead I, and QRS complex duration of 120 ms. These findings gradually resolved in parallel with the improvement in their symptoms.

Conclusion: Severe quetiapine poisoning may cause electrographic changes. Further studies are needed to determine the utility of these electrocardiogram findings for predicting the severity of quetiapine poisoning.

Introduction: Many patients acutely self-poisoned with organophosphorus insecticides have co-ingested ethanol. Currently, profenofos 50% emulsifiable concentrate (EC50) is commonly ingested for self-harm in Sri Lanka. Clinical experience suggests that ethanol co-ingestion makes management more difficult. Therefore, we aimed to determine the relationships between plasma ethanol concentration, plasma profenofos concentration and its toxicokinetics, and clinical outcome in acute profenofos self-poisoning.

Methods: Demographic and clinical data, including a history of ethanol ingestion and blood samples, were prospectively collected from all cases of acute poisoning with profenofos EC50 presenting to Teaching Hospital Peradeniya, Sri Lanka, over four years. Plasma samples were analyzed by gas chromatography-mass spectrometry to quantify the ethanol (n = 99) and profenofos (n = 30 [15 with ethanol, 15 without ethanol]) concentrations. The PKSolver program was used to calculate the toxicokinetic parameters.

Results: Of 99 patients (male 78/99) with acute profenofos self-poisoning, 50 reported a history of ethanol co-ingestion. Plasma from 44 of 99 profenofos-poisoned patients had detectable ethanol concentrations. No statistical difference was observed between the mortality in the ethanol group and the no ethanol group (5/44 [11.4%] versus 3/55 [5.5%]; P = 0.461). Similarly, the median half-lives of plasma profenofos absorption in the ethanol and no ethanol groups (0.1 h and 0.1 h, respectively; time 0-24 h) were not statistically different (P = 0.6594). However, the median half-life of plasma profenofos elimination was significantly longer in the ethanol group than the no ethanol group (23.1 h and 9.9 h, respectively; time 0-24 h; P = 0.0002). According to the regression analysis, the half-life of plasma profenofos elimination was longer by 29.4 h in the ethanol group (P = 0.013).

Discussion: No significant differences in outcomes, including death and endotracheal intubation rates, were found between those who did and did not co-ingest ethanol. No differences were found in toxicokinetic variables between the ethanol and no ethanol groups, but the ethanol group had a longer elimination half-life.

Conclusion: The co-ingestion of ethanol leads to a slowing of the elimination kinetics of profenofos. However, the study did not reveal a significant impact of ethanol co-ingestion on clinical outcomes.