Clinical Toxicology最新文献

Introduction: Fentanyl has replaced diacetylmorphine (heroin) as the primary illicit opioid in the United States. Over the last several years, exposures to illicit fentanyl in small children have increased nationally. We hypothesized that the increase in illicit fentanyl in the community, as measured by regional drug seizures, would be associated with the number of pediatric exposures to illicit fentanyl.

Methods: To assess the number of pediatric illicit fentanyl exposures, we searched the regional poison center database for human exposures in children under 6 years old from January 1, 2019-December 31, 2023. We searched for all cases with fentanyl in the substance field and excluded cases that identified prescription fentanyl in the substance code, product code, or had an exposure reason not consistent with illicit fentanyl. We quantified illicit fentanyl drug seizures in our state by using the Drug Enforcement Administration data. We used Poisson regression to assess the association between drug availability in the community (drug seizures) and pediatric fentanyl exposures.

Results: Between 2019 and 2023, there was an increase in both illicit fentanyl drug seizures (from 11.7 kg/year to 177 kg/year) and pediatric fentanyl exposures (from zero to 16), and there was a significant association (incident rate ratio 1.90; 95% CI: 1.50-2.53; P <0.001) between these rates.

Discussion: We report a strong association between drug availability in the community and pediatric exposures, suggesting that drug seizure data may be a valuable tool for poison centers, medical toxicologists, and public health officials.

Conclusions: Our data suggest that monitoring regional drug seizure data may be a tool to determine new trends in pediatric exposure, guide research in the area, and target outreach and education.

Introduction: Ethyl chloride misuse remains a prevailing concern due to its accessibility, but detailed descriptions of the features of toxicity are limited to sporadic reports, resulting in knowledge gaps in their clinical features and diagnosis.

Objective: To describe the clinical features, treatment, and outcomes of patients reported in the literature who developed toxicity from inhalational use of ethyl chloride.

Methods: We reviewed relevant literature over the past 50 years and analyzed the characteristics and outcomes of patients with toxicity from the inhalational use of ethyl chloride.

Results: A total of 21 studies from 1979 to 2024 were identified, making available 22 patients for analysis. Their median age was 40 years (range 16-62 years), and there were more than four times as many males as females. Ethyl chloride-containing cleaning solvents (8/22, 36%) were most commonly used. Regular inhalation of ethyl chloride was documented in approximately two-thirds of the patients (14/22, 66%), with a median duration of five months of misuse (range 2-360 months). A large proportion of patients (15/22, 68%) inhaled ethyl chloride again within a week from the onset of toxicity. Although features of cerebellar dysfunction were very common at presentation (13/16, 81%), abnormalities on neuroimaging studies were rare. Death occurred in more than a quarter of cases (6/22, 27%), with patients either already deceased or dying shortly after. Half (3/6) of these deaths were directly attributable to the development of lethal cardiac dysrhythmias. Conversely, most survivors either improved or fully recovered within a few days to weeks (14/16, 88%), independent of their presenting symptoms, clinical signs, and the treatments they received.

Discussion: Ethyl chloride users are likely young or middle-aged males, and clinical features of toxicity can range from transient neurological symptoms to cardiac dysrhythmias and death. The prominence of neurotoxicity may be attributed to the lipophilic nature of ethyl chloride and its tendency to accumulate in neural tissue, while cardiac dysrhythmias have been attributed to cardiac sensitization to catecholamines through ethyl chloride-induced inhibition of potassium, calcium, and sodium channels.

Conclusions: Toxicity from the inhalational misuse of ethyl chloride should be considered in young or middle-aged males presenting with acute cerebellar dysfunction. We recommend that suspected cases undergo telemetric monitoring for 24 h, especially when tachycardia and/or palpitations are present, as deaths from lethal cardiac dysrhythmias are not uncommon.

Introduction: The alpine pit viper, Trimeresurus gracilis, is an endemic species in Taiwan. The incidence of human envenoming is rare.

Case summaries: We present three events in two patients bitten by Trimeresurus gracilis. In the first patient, envenoming inflicted pain, local bleeding, hemorrhagic bulla, and progressive swelling, leading to necrosis of the bite wound. In the second patient, the two snakebites caused pain and progressive swelling. There were no systemic effects such as organ damage or neurological deficits observed. A paraspecific antivenom against Trimeresurus stejnegeri and Protobothrops mucrosquamatus was used to treat both patients, with a favorable outcome in each.

Discussion: Combined with the clinical manifestations of two previously reported cases of Trimeresurus gracilis envenoming, the known effects of Trimeresurus gracilis venom in humans include local toxicities, severe soft-tissue damage, compartment syndrome, and coagulopathy without spontaneous systemic bleeding. The paraspecific antivenom, which has demonstrable cross-neutralization effects in animal studies, appeared to be effective against the local toxicities as the patients showed prompt cessation of the progression of their swelling.

Conclusions: The knowledge of clinical manifestations and management approaches to Trimeresurus gracilis envenoming is helpful for patient care. The use of the paraspecific antivenom should be considered in managing such envenoming.

Introduction: Alcohol withdrawal is typically managed using benzodiazepines. However, modulation of both γ-aminobutyric acid-A and N-methyl-d-aspartate-receptors through ethanol provision may provide an alternative management strategy. This systematic review critically analyses the evidence surrounding the use of oral or intravenous ethanol for the management of alcohol withdrawal syndrome.

Methods: Systematic searches of ProQuest - American Psychological Association, PsycInfo, MEDLINE and PubMed Central, Web of Science and Embase were performed (Prospero registration number: CRD42023425224). Search criteria were: Population = Patients receiving pharmacological interventions to treat or prevent alcohol withdrawal in a healthcare setting. Intervention = intravenous or enteral ethanol. Comparator = standard care, benzodiazepines, carbamazepine, adjunct medications including sedatives, or no comparator. Outcomes = complication rates, symptom scores, length of stay in healthcare settings. Exclusions were: preclinical studies, participants less than 18 years old, non-peer reviewed literature, poor study design or poor data quality. Study quality was assessed using an adapted National Institute for Health and Care Research quality tool. A narrative data synthesis approach was adopted.

Results: Eight thousand two hundred and four studies were retrieved. Ten were included in the final analysis. Overall study quality was poor. Seven studies reported treatment outcomes that were comparable to a control arm or in which ethanol conferred no detrimental effect. Three studies reported positive outcomes, and one study reported worse outcomes following ethanol administration.

Discussion: The review identified heterogeneity in study design and limited reporting surrounding patient demographics, patient alcohol use history and the practicalities of ethanol administration. As such, implementation of ethanol prescribing for the management of alcohol withdrawal is currently limited due to the quality and translatability of existing data surrounding its use.

Conclusions: Further studies are required with more transparent and complete outcome reporting and practical implementation recommendations in order to facilitate the translation of ethanol prescribing for the management of alcohol withdrawal syndrome.

Introduction: Unfortunately, children are not spared from the devastating effects of the ongoing opioid epidemic. In rare cases, young children exposed to opioids present with unique neuroimaging findings affecting the white matter, reminiscent of what was once seen with diacetylmorphine (heroin)-associated leukoencephalopathy. This constellation of findings is termed the pediatric opioid use-associated neurotoxicity with cerebellar edema (POUNCE) syndrome.

Case summary: A 31-month-old child was found floppy and unresponsive. Upon hospital arrival, there was right gaze deviation, shaking of the arms and legs, miosis, and bradypnea. Response to naloxone was incomplete, and methadone was confirmed in the child's urine.

Images: Magnetic resonance imaging of the brain performed 24 h after admission showed abnormal T2/FLAIR hyperintensity with associated restricted diffusion symmetrically involving the cerebellar hemispheres.

Conclusion: The imaging findings, although far from pathognomonic, should be recognizable by radiologists and toxicologists when considering possible opioid exposure in a young child.

Introduction: Volatile nitrites, such as amyl nitrite, are used recreationally to enhance sexual experience and provide a feeling of euphoria. They are associated with severe adverse reactions including methaemoglobinaemia and maculopathy. The aim of this study was to explore the epidemiology and clinical effects of volatile nitrite exposures reported to the Victorian Poisons Information Centre in Australia over a 10-year period.

Methods: This was a retrospective, observational study of poison centre call records. Data were extracted for all exposures to volatile nitrites reported from 2013 to 2022.

Results: There were 132 calls about volatile nitrites, representing 122 exposures, with a more than five-fold increase in the annual number of exposures (from five in 2013 to 26 in 2022). Ingestion (49.2%) and inhalation (27.9%) were the most common routes of exposure. Seventy-six (62.3%) patients reported one or more symptoms related to volatile nitrite exposure. The most common symptoms were light-headedness/dizziness (20.5%), oro-mucosal irritation (15.6%), ocular irritation (14.8%), nasal irritation (12.3%), and nausea/vomiting (9.8%). Less common, but potentially serious, adverse effects included methaemoglobinaemia (4.1%), hypoxia (1.6%) and hypotension (0.8%). Symptom severity was usually classified as minor (70/76, 92.1%) at the time of the poisons centre call. Fifty-four (44.3%) patients were either in the hospital when the poisons centre was contacted or were referred to the hospital by the poisons centre.

Discussion: The increase in reported volatile nitrite exposures observed in this study aligns with epidemiological data showing an increase in volatile nitrite usage in Australia. The findings about the nature of exposures and symptoms experienced can be used to inform harm reduction and education efforts for community members and health professionals.

Conclusions: Exposures to volatile nitrites reported to an Australian poisons centre increased between 2013 and 2022. More than 40% of exposures resulted in a hospital presentation. Methaemoglobinaemia was reported in 4.1% of cases.