J Med Toxicol
· 2024 Oct · PMID 39304613
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INTRODUCTION: Case reports are perceived as having diminished value relative to other study designs. It has been said that medical toxicology (MT) is based largely upon case report literature and thought to be unique in...INTRODUCTION: Case reports are perceived as having diminished value relative to other study designs. It has been said that medical toxicology (MT) is based largely upon case report literature and thought to be unique in this regard. We sought to quantify recent MT publication of case reports compared with top periodicals from emergency medicine (EM) and internal medicine (IM) journals. METHODS: A retrospective review examined 5 years of articles in 6 U.S.-based medical journals-MT (Journal of Medical Toxicology, Clinical Toxicology), EM (Annals of Emergency Medicine, Journal of Emergency Medicine), and IM (JAMA Internal Medicine, New England Journal of Medicine) was performed using on-line resources. Every article in each issue was categorized into Case report vs. Research and Analysis articles vs. Excluded. "Case report" was defined as one (or ≤ 5) individual patients, one patient's data, etc. Total articles per issue were reported after removing Excluded items. RESULTS: Between 2018 and 2022, these 6 periodicals published 522 issues; with 2644 case reports; and 8246 total included articles. Comparison of MT case reports vs. EM revealed a significant difference and odds (Odds Ratio = 1.7, (95% CI: [1.49, 2.03], p < 0.001); MT compared with IM was not significantly different (Odds Ratio = 1.1, (95% CI: [0.96, 1.30], p = 0.150). The percent of case reports increased in the IM and EM journals compared with a relative decrease in the MT journals. Cumulative case report precents were consistently greater in EM and IM than in MT. CONCLUSION: In the past 5 years, MT journals published fewer and had a declining trend of case reports compared with leading EM and IM journals. Future research is needed to determine the effect on MT practice resulting from the diminished body of case report literature.
Mazer-Amirshahi M, Wax P, Dunavin A
… +2 more, Mycyk MB, Nelson LS
J Med Toxicol
· 2024 Oct · PMID 39266932
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More than 20 years that have elapsed since the inaugural American College of Medical Toxicology Spring Conference in 2002. During this time, the now ACMT Annual Scientific Meeting has grown in many ways, as demonstrated...More than 20 years that have elapsed since the inaugural American College of Medical Toxicology Spring Conference in 2002. During this time, the now ACMT Annual Scientific Meeting has grown in many ways, as demonstrated by the increase in attendance and abstract submissions, and diversification of educational offerings, and partners. Most importantly, the scientific rigor and presentation of new knowledge has continued to mature, and the conference is now firmly rooted in the annual educational schedule for medical toxicologists. In anticipation of the upcoming 2025 ASM, we reflect upon the evolution and growth of ACMT's research and educational agendas, and the Annual Scientific Meeting itself.
Hughes A, Amaducci A, Campleman SL
… +11 more, Li S, Costantini M, Spyres MB, Spungen H, Kent J, Falise A, Culbreth R, Wax PM, Brent J, Aldy K, Toxicology Investigators Consortium Study Group
J Med Toxicol
· 2024 Oct · PMID 39256327
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Since 2010, the American College of Medical Toxicology (ACMT) Toxicology Investigators Consortium (ToxIC) has maintained the ToxIC Core Registry, a national case registry of in-hospital and clinic patient consultations s...Since 2010, the American College of Medical Toxicology (ACMT) Toxicology Investigators Consortium (ToxIC) has maintained the ToxIC Core Registry, a national case registry of in-hospital and clinic patient consultations submitted by medical toxicology physicians. Deidentified patient data entered into the registry includes patient demographics, reason for medical toxicology evaluation, exposure agents, clinical signs and symptoms, treatments and antidotes administered, and mortality. This fourteenth annual report provides data from 7392 patients entered into the Core Registry in 2023 by 36 participating sites comprising 61 distinct healthcare facilities, bringing the total case count to 102331 between 2010 and 2023. Ethanol was the most commonly reported exposure agent class (24.4%), followed by opioids (22.7%), non-opioid analgesics (16.7%), and antidepressants (11.7%). For the first time since the registry's initiation, in 2023, ethanol was the leading agent of exposure. There were 98 fatalities (case fatality rate of 1.3%). Additional descriptive analyses in this annual report were conducted to describe the reasons for medical toxicology consultation by age in 2023, and yearly trends for opioid and psychoactive exposures, physostigmine and rivastigmine treatments, and acetaminophen exposures treated with fomepizole.
J Med Toxicol
· 2024 Oct · PMID 39179942
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Likelihood ratios compare two values (i.e., case rates) in order to illustrate the magnitude of the difference between the two. This ratio increases the confidence one can have in a diagnostic test from a different vanta...Likelihood ratios compare two values (i.e., case rates) in order to illustrate the magnitude of the difference between the two. This ratio increases the confidence one can have in a diagnostic test from a different vantage point than that of sensitivity and specificity. The calculations of likelihood ratios are presented along with a simplified approach. Likelihood ratios are another tool the toxicologist should employ in their understanding of statistics and probability.
Spadaro A, Lee ASY, Pineda H
… +5 more, Ruck B, Calello DP, Greller HA, Nelson LS, Parris MA
J Med Toxicol
· 2024 Oct · PMID 39174849
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INTRODUCTION: Thallium is a highly toxic metal, with most publications demonstrating poisoning from thallium salts. We report on a patient with elevated serum and urine thallium concentrations from an intentional ingesti...INTRODUCTION: Thallium is a highly toxic metal, with most publications demonstrating poisoning from thallium salts. We report on a patient with elevated serum and urine thallium concentrations from an intentional ingestion of elemental thallium purchased from the internet for self-harm. CASE REPORT: The regional poison center was contacted about an 18-year-old man who ingested a fragment from a 100-gram bar reported to be elemental thallium. Serial serum and urine thallium concentrations were obtained. Prussian blue was started on hospital day (HD) 2. A metal fragment was seen on abdominal x-ray and removed via colonoscopy on HD3. The ingested fragment was analyzed via inductively coupled plasma mass spectrometry (ICP-MS) and found to be 87.0% elemental thallium. The initial serum thallium concentration obtained on HD1 was 423.5 mcg/L (reference range < 5.1 mcg/L), which subsequently decreased to 4.5 mcg/L, 29 days after the ingestion. An initial random urine thallium concentration obtained on HD 3 was 1850.5 mcg/g creatinine (reference range < 0.4 mcg/g creatinine). The patient remained hospitalized for 23 days and, when seen in follow-up, had not developed any signs or symptoms of thallium toxicity. DISCUSSION: Elemental thallium ingestion is a rare toxicologic exposure, with limited published clinical and analytical experience to guide management. This case report describes a patient with ingestion of elemental thallium who developed elevated serum and urine thallium concentrations and was treated with Prussian blue. Despite having elevated serum and urine thallium concentrations consistent with previous fatal exposures, more evidence is needed to understand the differences between elemental thallium and thallium salts.
Smith GA, Burgess A, Badeti J
… +5 more, Rine NI, Gaw CE, Middelberg LK, Spiller HA, Hays HL
J Med Toxicol
· 2024 Oct · PMID 39168936
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INTRODUCTION: This study investigated exposures involving ∆8-tetrahydrocannabinol (∆8-THC) reported to US poison centers (PCs), including variation among states and regions. It evaluated whether the ∆8-THC exposure rate...INTRODUCTION: This study investigated exposures involving ∆8-tetrahydrocannabinol (∆8-THC) reported to US poison centers (PCs), including variation among states and regions. It evaluated whether the ∆8-THC exposure rate was lower among states with ∆8-THC regulations and states where cannabis (∆9-THC) use was legal. METHODS: National Poison Data System data for ∆8-THC exposures in 2021-2022 were analyzed, including comparisons of state and regional population-based exposure rates. RESULTS: There were 4,925 exposures involving ∆8-THC as the primary substance reported to US PCs from January 1, 2021, to December 31, 2022, with 69.8% of these reported in the US South. The rate of exposure per 100,000 US population increased by 79.2% from 0.53 in 2021 to 0.95 in 2022. In 2022, the mean rate of ∆8-THC exposures in states where cannabis use was illegal was 1.64 per 100,000 population (95% CI: 1.08-2.20) compared with 0.52 (95% CI: 0.29-0.76) in states where cannabis use was legal (P = 0.0010). In 2022, the mean rate of ∆8-THC exposures in states where ∆8-THC was unregulated was 1.36 per 100,000 population (95% CI: 0.95-1.77) compared with 0.17 (95% CI: 0.06-0.27) in states where ∆8-THC was banned (P < 0.0001). CONCLUSIONS: The rate of ∆8-THC exposures reported to US PCs increased by 79% from 2021 to 2022, with the US South accounting for more than two-thirds of exposures. The rate of ∆8-THC exposures reported to PCs was significantly lower among states where ∆8-THC was banned and among states where cannabis use was legal. Consistent regulation of ∆8-THC across all states should be adopted.
Daneshmend A, Gould A, Hudson S
… +3 more, Archer JRH, Dargan PI, Wood DM
J Med Toxicol
· 2024 Oct · PMID 39107657
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INTRODUCTION: Vortioxetine is an antidepressant with a multimodal mechanism of action. It is used as a treatment option for patients with major depressive episodes. There have only been two previously reported non-fatal...INTRODUCTION: Vortioxetine is an antidepressant with a multimodal mechanism of action. It is used as a treatment option for patients with major depressive episodes. There have only been two previously reported non-fatal overdoses of vortioxetine; neither of these were analytically confirmed There has also been one case of serotonin syndrome potentially related to vortioxetine and two deaths where vortioxetine was detected. We report here a non-fatal analytically confirmed case of vortioxetine overdose. CASE REPORT: A 32-year-old male presented to the emergency department (ED) 12-13 h after oral ingestion of 1,260 mg of vortioxetine and 350 mg of diazepam. A family member reported that he had been drowsy after the overdose, but his level of consciousness and observations (heart rate, blood pressure and temperature) were normal on review by the pre-hospital emergency services and on arrival to the ED. During a period of observation, he did not develop any features of serotonin syndrome or any other significant toxicity. Toxicological analysis of a blood sample taken in the ED detected vortioxetine (plasma concentration 457 ng/mL 10 h after ingestion) and sub-therapeutic concentrations of diazepam and pregabalin. DISCUSSION: Despite having a plasma vortioxetine concentration nearly 15-times therapeutic vortioxetine concentrations, this patient did not develop any significant toxicity. In particular he did not develop any clinical or biochemical features of serotonin toxicity that would be expected with this class of antidepressant. Additional reporting of analytically confirmed vortioxetine overdoses will allow clinicians and licensing authorities to further understand the safety of this medication in overdose.
J Med Toxicol
· 2024 Oct · PMID 39103667
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INTRODUCTION: Propylhexedrine is an over-the-counter nasal decongestant used recreationally for amphetamine-like effects. Prior reports have associated intravenous misuse with brainstem dysfunction and diplopia. This is...INTRODUCTION: Propylhexedrine is an over-the-counter nasal decongestant used recreationally for amphetamine-like effects. Prior reports have associated intravenous misuse with brainstem dysfunction and diplopia. This is a case of propylhexedrine ingestion resulting in neurological impairment with associated MRI findings. CASE REPORT: A 21-year-old man presented with neurologic symptoms after ingesting propylhexedrine extracted from a 250 mg nasal inhaler into a lemon juice solution following recommendations from an online forum. He also followed recommendations to simultaneously ingest 1 g L-arginine to theoretically mitigate the risk of vasoconstriction. He developed flushing and euphoria before falling asleep. He awoke 12 h later with dizziness, intractable vomiting, diplopia, ataxia, dysmetria, and spontaneous horizontal nystagmus. Magnetic resonance imaging (MRI) revealed T2 enhancement concerning for vasogenic edema of the right posterior limbs of the internal capsule extending into the midbrain, cerebellar peduncles, and cerebellar white matter. Workup for primary vascular or autoimmune etiologies was unrevealing. Expanded drug testing was positive for mitragynine and THC. Blood analyzed via liquid chromatography quadrupole time-of-flight mass spectrometry was positive for propylhexedrine. On hospital day 6, the patient was discharged to physical rehabilitation with unresolved dysmetria and ataxia. DISCUSSION: Recreational oral misuse of propylhexedrine may be associated with neurologic injury. MRI findings in this case demonstrated vasogenic edema suggesting vasospasm as a possible etiology. Serum testing confirmed the presence of propylhexedrine. Although testing was also positive for mitragynine and THC, these have not been associated with similar neurologic deficits or MRI findings.
Inoue F, Okazaki Y, Huh K
… +3 more, Ichiba T, Chiba T, Namera A
J Med Toxicol
· 2024 Oct · PMID 39093496
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INTRODUCTION: Quetiapine is available in both immediate-release (IR) and extended-release (XR) formulations. Quetiapine XR overdose is known to cause delayed increase in serum quetiapine concentrations. However, it is no...INTRODUCTION: Quetiapine is available in both immediate-release (IR) and extended-release (XR) formulations. Quetiapine XR overdose is known to cause delayed increase in serum quetiapine concentrations. However, it is not certain whether quetiapine IR overdose would similarly cause a delayed increase in serum quetiapine concentrations. CASE REPORT: A 57-year-old woman with depression who was taking half a tablet of 25 mg quetiapine IR daily was transported to our emergency department with a complaint of disturbance of consciousness 12 h after a quetiapine IR overdose. On arrival, her initial vital signs were heart rate of 116 beats per minute, blood pressure of 77/43 mm Hg, and oxygen saturation of 91% under 10 L oxygen administration. Whole body plain computed tomography showed a large amount of gastric hyperdense content suggesting pharmacobezoar with a volume of 71.2 ml. After treatment with respiratory and circulatory support, gastric lavage was performed. Her disturbance of consciousness persisted until day 5, and she was extubated on day 7. The serum concentrations of quetiapine were 2690 ng/mL at 12 h after overdose, 5940 ng/mL at 40 h, and 350 ng/mL at 124 h after overdose. Serum concentrations of other co-ingestions were all below lethal levels. CONCLUSION: A massive quetiapine IR overdose with pharmacobezoars can cause a delayed increase in serum quetiapine concentrations.
Glass KA, Stoecker ZR, LeRoy J
… +3 more, Palmer CL, Stipek J, Boley S
J Med Toxicol
· 2024 Oct · PMID 38992233
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BACKGROUND: Acetaminophen toxicity remains one of the most common causes of liver failure and is treated with a course of n-acetylcysteine (NAC). This exceptionally effective medication is traditionally administered usin...BACKGROUND: Acetaminophen toxicity remains one of the most common causes of liver failure and is treated with a course of n-acetylcysteine (NAC). This exceptionally effective medication is traditionally administered using a complicated three-bag protocol that is prone to administration errors. OBJECTIVE: We aimed to assess whether switching to a novel two-bag protocol (150 mg/kg over 1 h followed by 150 mg/kg over 20 h) reduced administration errors while not increasing liver injury or anaphylactoid reactions. METHODS: This was a retrospective chart review of hospital encounters for patients with acetaminophen toxicity, comparing outcomes before and after the change from a three-bag protocol to a two-bag protocol at two affiliated institutions. The primary outcome was incidence of medication errors with secondary outcomes including acute liver injury (ALI) and incidence of non-anaphylactoid allergic reactions (NAAR). The study was approved by the health system's Institutional Review Board. RESULTS: 483 encounters were included for analysis (239 in the three-bag and 244 in the two-bag groups). NAAR were identified in 11 patients with no difference seen between groups. Similarly, no differences were seen in ALI. Medication administration errors were observed significantly less often in the two-bag group (OR 0.24) after adjusting for confounders. CONCLUSION: Transitioning to a novel two-bag NAC regimen decreased administration errors. This adds to the literature that two-bag NAC regimens are not only safe but also may have significant benefits over the traditional NAC protocol.
Brent J, Wax P, Culbreth R
… +2 more, Campleman S, Aldy K
J Med Toxicol
· 2024 Jul · PMID 38935267
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The Toxicology Investigators Consortium (ToxIC) was launched as a prospective multi-center registry of cases who receive medical toxicology consultations. Now, with over 100,000 cases, the Core Registry continues to addr...The Toxicology Investigators Consortium (ToxIC) was launched as a prospective multi-center registry of cases who receive medical toxicology consultations. Now, with over 100,000 cases, the Core Registry continues to address many medical toxicology research questions and has served as the foundation for multiple sub-registries, including the North American Snakebite Registry and the Medications for Opioid Use Disorder sub-registry. ToxIC also has evolved a portfolio of non-registry-based projects utilizing medical toxicology physician site principal investigators who enroll patients through emergency departments, irrespective of whether they received a medical toxicology consultation. These studies include the FDA-ACMT COVID-19 ToxIC Pharmacovigilance Project, which identifies adverse drug reactions related to the treatment of COVID-19, the Fentalog Study a toxico-surveillance study of suspected opioid overdose cases, the Drug Overdose Toxico-Surveillance Reporting Program which enrolls either suspected stimulant or opioid overdose cases, and the just being launched Real-World Examination of Naloxone for Drug Overdose Reversal project. Given ToxIC's experience in multi-center studies and its well-developed infrastructure, it is well-positioned to provide a nimble response on the part of the medical toxicology community to addressing evolving toxicological threats, drug and chemical toxicosurveillance, and other important medical toxicology priorities.
Marshall S, Ryan E, Rivera J
… +2 more, Reynolds L, Atti S
J Med Toxicol
· 2024 Jul · PMID 38861153
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INTRODUCTION: Glucagon-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 tha...INTRODUCTION: Glucagon-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. METHODS: We 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. RESULTS: A 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. CONCLUSION: Exposures 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.
J Med Toxicol
· 2024 Jul · PMID 38839732
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INTRODUCTION: Synthetic cannabinoid receptor agonists (SCRAs) are associated with significant toxicity and are increasingly used in electronic vaping devices. We assessed the availability of SCRA vaping products to UK pu...INTRODUCTION: Synthetic cannabinoid receptor agonists (SCRAs) are associated with significant toxicity and are increasingly used in electronic vaping devices. We assessed the availability of SCRA vaping products to UK purchasers on the surface web. METHODS: An internet snapshot survey was performed between October 2022 and January 2023 on 'google.com' using the search terms "buy c-liquid vape", "buy herbal incense vape liquid", "buy cannabis vape liquid", "buy hashish vape liquid", "buy K2 vape liquid". RESULTS: 62 websites selling 128 SCRA vaping brands were identified. Most were purportedly based in the USA (41 websites, 66%) and most sold other controlled substances. Purchase incentives offered included discreet packaging (38, 61%), discounts for bulk purchase (34, 55%) and tracked delivery (30, 48%). Many websites stated SCRA products were: not for human consumption (41, 66%), for research purposes only (15, 24%), or legal (28, 45%). Websites sold a median (IQR) of 16 (7-25) SCRA vaping brands. Almost all were bottles of vaping liquid (1220/1225, 99.6%). The most common bottle size was 5mL (60%), the median (IQR) total volume of SCRA liquid per sale was 50mL (10-200mL). Median (IQR) price was £3.39/mL (£2.01/mL- £5.29/mL). Price decreased with increasing volume purchased (£6.58/mL for ≤ 5mL, £1.60/mL for > 200mL). CONCLUSION: SCRA vaping products are easily obtainable online, in both small and bulk quantities. Information provided to purchasers on safety and legality is lacking or misleading. Further studies are needed to confirm the chemistry of these products. Policymakers should consider steps to limit the potential harm caused by the purchase and use of these products.