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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 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. [ABSTRACT FROM AUTHOR]

The article discusses the use of nalmefene as an alternative treatment for opioid overdose. Nalmefene is an opioid antagonist that was recently approved by the US FDA for emergency treatment of opioid overdose. However, the article argues that nalmefene should not replace naloxone as the primary opioid antidote at this time. The authors express concerns about the lack of clinical data supporting the effectiveness and safety of nalmefene, as well as the potential for longer-lasting withdrawal symptoms and the need for extended medical observation. They recommend further clinical studies and comparative studies with naloxone to determine the differences in effectiveness and adverse outcomes. [Extracted from the article]

Background: Gender diversity in both emergency medicine and medical toxicology has grown over the last decade. However, disparities in promotion, awards, and speakership still exist. No studies have examined gender disparities in authorship in medical toxicology journals. Research Questions: Does the proportion of female first authors and female senior authors in medical toxicology publications increase over time? What factors predict female authorship in the first author or last author positions in two major medical toxicology journals? Methods: We performed a retrospective review of all non-abstract publications in two medical toxicology journals, Clinical Toxicology and Journal of Medical Toxicology, between 2011 and 2020. We collected author names, number of authors, publication type, and publication year. Author names were used to identify author gender using Gender-API integrative tool. Data on the percentages of female medical toxicology fellows and medical toxicologists was provided by the American Board of Emergency Medicine (ABEM). Results: A total of 2212 publications were reviewed and 2171 (97.9%) were included in the dataset. Overall, 31.7% of first authors were identified as female and 67.0% were identified as male by the Gender-API tool. There were 46.8% male-male author dyads, 24.2% female-male author dyads, 12.1% male-female author dyads, and 5.7% female-female author dyads. Predictors of female first authorship included research and case report articles, and percentage of ABEM female toxicologists. Predictors of female senior authorship included number of authors and percentage of ABEM female toxicologists. The proportion of female authorship in both categories increased over the study period. Conclusions: The frequency of female authorship in the first author position has grown over the last decade and is associated with increasing female representation in medical toxicology and specific manuscript subtypes, specifically research manuscripts. [ABSTRACT FROM AUTHOR]

In many countries, adherence testing is used to monitor consumption behavior or to prove abstinence. Urine and hair are most commonly used, although other biological fluids are available. Positive test results are usually associated with serious legal or economic consequences. Therefore, various sample manipulation and adulteration strategies are used to circumvent such a positive result. In these critical review articles on sample adulteration of urine (part A) and hair samples (part B) in the context of clinical and forensic toxicology, recent trends and strategies to improve sample adulteration and manipulation testing published in the past 10 years are described and discussed. Typical manipulation and adulteration strategies include undercutting the limits of detection/cut-off by dilution, substitution, and adulteration. New or alternative strategies for detecting sample manipulation attempts can be generally divided into improved detection of established urine validity markers and direct and indirect techniques or approaches to screening for new adulteration markers. In this part A of the review article, we focused on urine samples, where the focus in recent years has been on new (in)direct substitution markers, particularly for synthetic (fake) urine. Despite various and promising advances in detecting manipulation, it remains a challenge in clinical and forensic toxicology, and simple, reliable, specific, and objective markers/techniques are still lacking, for example, for synthetic urine. [ABSTRACT FROM AUTHOR]

As a continuation of part A, focusing on advances in testing for sample manipulation of urine samples in clinical and forensic toxicology, part B of the review article relates to hair, another commonly used matrix for abstinence control testing. Similar to urine manipulation, relevant strategies to manipulate a hair test are lowering drug concentrations in hair to undercut the limits of detection/cut-offs, for instance, by forced washout effects or adulteration. However, distinguishing between usual, common cosmetic hair treatment and deliberate manipulation to circumvent a positive drug test is often impossible. Nevertheless, the identification of cosmetic hair treatment is very relevant in the context of hair testing and interpretation of hair analysis results. Newly evaluated techniques or elucidation of specific biomarkers to unravel adulteration or cosmetic treatment often focused on specific structures of the hair matrix with promising strategies recently proposed for daily routine work. Identification of other approaches, e.g., forced hair-washing procedures, still remains a challenge in clinical and forensic toxicology. [ABSTRACT FROM AUTHOR]

The article discusses the importance of Letters to the Editor (LTEs) in facilitating scientific discourse and serving as a forum for public discussion. It acknowledges the rise of informal scientific writing on social media but argues that LTEs remain valuable for critiquing and expanding scholarly work. The article highlights the limitations of social media in disseminating accurate information and emphasizes the need for professionalism and fact-checking in LTEs. It provides guidance on writing effective LTEs, including adhering to specific instructions and focusing on specific points. The article also encourages submissions to the Poison Pen section of the Journal of Medical Toxicology, which publishes letters related to recent articles and contemporary issues in medical toxicology. It emphasizes the importance of clear and accurate writing and encourages authors of all levels to submit LTEs. The article concludes by inviting readers to engage in post-publication peer review and contribute to the intellectual forum of scientific enterprise. [Extracted from the article]

Hospital-treated intentional self-poisoning is common. The possibility of changed (increased) suicidal behaviors during the COVID-19 pandemic has been raised. To compare frequencies in self-poisoning events (SPEs) and the proportions with in-hospital mortality, in the year prior to and following the official onset of the COVID-19 pandemic, in a population of hospital-treated self-poisoning patients in Iran. All self-poisoned patients admitted to Loghman-Hakim Hospital, a clinical toxicology specialty hospital in Tehran, were included. The frequency of SPEs was compared between the one-year periods immediately before and after the onset of COVID-19 pandemic using Poisson regression. Differences in proportions of in-hospital mortality were also compared using logistic regression. A total of 14,478 patients with 15,391 SPEs (8,863 [61.2%] females) were evaluated in the study. There was no difference in the overall frequency of SPEs (relative risk [RR] of 0.99 [CI95% 0.96–1.03]), but a small increase in males (RR 1.07; 1.02–1.13) and a minor decrease in females (RR 0.95; 0.91–0.99). In total, 330 patients died (2.3% of all SPEs). There was no difference in overall in-hospital mortality odds ratio (OR: 0.98 [0.79–1.22]), in females (OR = 1.14 [0.80–1.60]) or males (OR = 0.92 [0.69–1.23]). There was no change in the frequency of SPEs and no difference in the in-hospital mortality proportions, suggesting that the COVID-19 pandemic had little or no effect on these aspects of suicidal behavior in Iran. [ABSTRACT FROM AUTHOR]

Introduction: Delta-8-tetrahydrocannabinol (THC) is a known isomer of delta-9-THC, both found naturally in the Cannabis sativa plant and thought to have similar potency. Delta-8-THC products are widely accessible in retail shops which may lead to a rise in pediatric exposures with substantial clinical effects. Case Report: This is a case series of four pediatric patients that were seen between June and September 2021. The patients presented with varied clinical symptoms including confusion, somnolence, seizure-like activity, hypotension, and tachycardia after exposure to delta-8-THC products obtained in retail shops. Basic urine drug screen immunoassays revealed positive results for cannabinoids in all patients. Subsequent confirmatory drug analysis of residual biological samples of blood and/or urine was sent to the University of California San Francisco Clinical Toxicology and Environment Biomonitoring Laboratory with the assistance of the Drug Enforcement Administration's Toxicology Testing Program (DEA TOX). Confirmatory testing revealed 11-nor-9-carboxy-delta-8-THC, the metabolite of delta-8-THC. Delta-9-THC and its metabolites were not detected on confirmatory testing in any of the cases. Discussion: Clinical effects of delta-8-THC in children include but are not limited to altered mental status, seizure-like activity, and vital sign abnormalities. Delta-8-THC exposure may lead to a positive urine drug screen for cannabinoids, but confirmatory testing is needed to differentiate from delta-9-THC. [ABSTRACT FROM AUTHOR]

Considering the rich background of Persian Medicine in the use of materia medica for the treatment of diseases, the huge burden of oral poisonings in the world, and the urgent need to find scientific solutions, the purpose of this study was to determine Avicenna's approach toward clinical toxicology and his proposed treatments for oral poisonings. In Al-Qanun Fi Al-Tibb, Avicenna addressed the materia medica for the treatments of oral poisonings after explaining the ingestion of different toxins and also elucidating the clinical toxicology approach toward poisoned patients. These materia medica were from different classes including emetics, purgatives, enemas, diaphoretics, antidiarrheals, inhaled drugs, sternutators, anticoagulants, antiepileptics, antitussives, diuretics, cooling drugs, stimulants, cardiotonic drugs, and heating oils. By applying different therapies, Avicenna endeavored to attain main goals in clinical toxicology that are comparable with modern medicine. They included removing the toxins from the body, decreasing the severity of the deleterious effects of toxins on the body, and counteracting the effects of toxins inside the body. Aside from introducing different therapeutic agents that played an important role in the treatment of oral poisonings, he emphasized the ameliorating effects of nutritive foods and beverages. Further research using other Persian medical resources is recommended to elucidate the applicable approaches and treatments for different poisonings. [ABSTRACT FROM AUTHOR]

Certain biological 'receptors' are known to generate disease conditions in the animal/human body. Small molecules, determined by the nature of their groups and shape in three dimensions, fit into the cavities of these receptors and deactivate them, thereby acting as 'drugs'. Several factors, such as pharmacokinetics, pharmacodynamics, metabolism, toxicology and clinical trials, play a crucial role in evaluating any drug. Drugs may be chiral, achiral or racemic in nature. These may be obtained either by extraction from a natural source or by semi-synthetic or synthetic methods. [ABSTRACT FROM AUTHOR]

Introduction: Poison Centers are vital to prevent and manage exposures to chemicals, toxins, and ionizing radiation. However, many countries still lack sufficient poison information center services. Within the World Health Organization’s Eastern Mediterranean Regional Office (EMRO) region, we were not able to identify a formal assessment of its toxicological resources. We sought to assess the clinical toxicological resources in the EMRO region and the attitudes, needs, and perspective of the workforce in that region. This was a two part survey study. First, we developed a poison center questionnaire and scoring system based on the World Health Organization's Guidelines for Establishing a Poison Center; this instrument was administered by phone to poison center directors and faculty in the EMRO region. Questions assessed for the presence or absence of important poison center capabilities listed in the WHO guidelines, and points were assigned based on response. Secondly, we administered an electronic workforce survey to clinical toxicology professionals in the region; participant eligibility for the workforce survey was based on the membership roster of MENATOX. Out of 22 EMRO countries, 16 countries have an established poison center, and 14 of 16 participated in the poison center survey.  The results reflected a wide variability in capabilities among countries. Areas such as call centers, clinical toxicology units, laboratory services, and data management were relatively lacking while some other areas including toxicovigilance, chemical incidents and emergencies, antidotes/antivenoms, poisoning information sources, and the availability of free services were relatively stronger. Twenty-seven out of 32 workforce respondents were physicians. Results from that survey highlighted a desire for more support from government and better compensation.Our study identified areas of need for the EMRO region. The poison center survey results reflect large disparities among countries with some areas being stronger than others. The workforce survey highlighted issues such as compensation and government recognition.Overall, a formal assessment of individual poison centers can provide benchmarks to drive improvement of services, but further research is needed to identify and characterize country-specific needs.Methods: Poison Centers are vital to prevent and manage exposures to chemicals, toxins, and ionizing radiation. However, many countries still lack sufficient poison information center services. Within the World Health Organization’s Eastern Mediterranean Regional Office (EMRO) region, we were not able to identify a formal assessment of its toxicological resources. We sought to assess the clinical toxicological resources in the EMRO region and the attitudes, needs, and perspective of the workforce in that region. This was a two part survey study. First, we developed a poison center questionnaire and scoring system based on the World Health Organization's Guidelines for Establishing a Poison Center; this instrument was administered by phone to poison center directors and faculty in the EMRO region. Questions assessed for the presence or absence of important poison center capabilities listed in the WHO guidelines, and points were assigned based on response. Secondly, we administered an electronic workforce survey to clinical toxicology professionals in the region; participant eligibility for the workforce survey was based on the membership roster of MENATOX. Out of 22 EMRO countries, 16 countries have an established poison center, and 14 of 16 participated in the poison center survey.  The results reflected a wide variability in capabilities among countries. Areas such as call centers, clinical toxicology units, laboratory services, and data management were relatively lacking while some other areas including toxicovigilance, chemical incidents and emergencies, antidotes/antivenoms, poisoning information sources, and the availability of free services were relatively stronger. Twenty-seven out of 32 workforce respondents were physicians. Results from that survey highlighted a desire for more support from government and better compensation.Our study identified areas of need for the EMRO region. The poison center survey results reflect large disparities among countries with some areas being stronger than others. The workforce survey highlighted issues such as compensation and government recognition.Overall, a formal assessment of individual poison centers can provide benchmarks to drive improvement of services, but further research is needed to identify and characterize country-specific needs.Results: Poison Centers are vital to prevent and manage exposures to chemicals, toxins, and ionizing radiation. However, many countries still lack sufficient poison information center services. Within the World Health Organization’s Eastern Mediterranean Regional Office (EMRO) region, we were not able to identify a formal assessment of its toxicological resources. We sought to assess the clinical toxicological resources in the EMRO region and the attitudes, needs, and perspective of the workforce in that region. This was a two part survey study. First, we developed a poison center questionnaire and scoring system based on the World Health Organization's Guidelines for Establishing a Poison Center; this instrument was administered by phone to poison center directors and faculty in the EMRO region. Questions assessed for the presence or absence of important poison center capabilities listed in the WHO guidelines, and points were assigned based on response. Secondly, we administered an electronic workforce survey to clinical toxicology professionals in the region; participant eligibility for the workforce survey was based on the membership roster of MENATOX. Out of 22 EMRO countries, 16 countries have an established poison center, and 14 of 16 participated in the poison center survey.  The results reflected a wide variability in capabilities among countries. Areas such as call centers, clinical toxicology units, laboratory services, and data management were relatively lacking while some other areas including toxicovigilance, chemical incidents and emergencies, antidotes/antivenoms, poisoning information sources, and the availability of free services were relatively stronger. Twenty-seven out of 32 workforce respondents were physicians. Results from that survey highlighted a desire for more support from government and better compensation.Our study identified areas of need for the EMRO region. The poison center survey results reflect large disparities among countries with some areas being stronger than others. The workforce survey highlighted issues such as compensation and government recognition.Overall, a formal assessment of individual poison centers can provide benchmarks to drive improvement of services, but further research is needed to identify and characterize country-specific needs.Conclusions: Poison Centers are vital to prevent and manage exposures to chemicals, toxins, and ionizing radiation. However, many countries still lack sufficient poison information center services. Within the World Health Organization’s Eastern Mediterranean Regional Office (EMRO) region, we were not able to identify a formal assessment of its toxicological resources. We sought to assess the clinical toxicological resources in the EMRO region and the attitudes, needs, and perspective of the workforce in that region. This was a two part survey study. First, we developed a poison center questionnaire and scoring system based on the World Health Organization's Guidelines for Establishing a Poison Center; this instrument was administered by phone to poison center directors and faculty in the EMRO region. Questions assessed for the presence or absence of important poison center capabilities listed in the WHO guidelines, and points were assigned based on response. Secondly, we administered an electronic workforce survey to clinical toxicology professionals in the region; participant eligibility for the workforce survey was based on the membership roster of MENATOX. Out of 22 EMRO countries, 16 countries have an established poison center, and 14 of 16 participated in the poison center survey.  The results reflected a wide variability in capabilities among countries. Areas such as call centers, clinical toxicology units, laboratory services, and data management were relatively lacking while some other areas including toxicovigilance, chemical incidents and emergencies, antidotes/antivenoms, poisoning information sources, and the availability of free services were relatively stronger. Twenty-seven out of 32 workforce respondents were physicians. Results from that survey highlighted a desire for more support from government and better compensation.Our study identified areas of need for the EMRO region. The poison center survey results reflect large disparities among countries with some areas being stronger than others. The workforce survey highlighted issues such as compensation and government recognition.Overall, a formal assessment of individual poison centers can provide benchmarks to drive improvement of services, but further research is needed to identify and characterize country-specific needs. [ABSTRACT FROM AUTHOR]

Synthetic cannabinoid receptor agonists (SCRAs) pose a danger to public health. This study focused on individuals experiencing recreational drug toxicity who had used 5F-MDMB-PICA. Patient records were evaluated regarding vital signs, Glasgow Coma Scale (GCS) and clinical features. Liquid chromatography coupled to high-resolution mass spectrometry (LC-HRMS) confirmed and quantified the presence of 5F-MDMB-PICA (and/or metabolites) as the only SCRA present in the serum of 71 patients. Cannabinoid activity was evaluated by a cannabinoid receptor (CB1) bioassay, to assess the relationship between serum concentrations and ex vivo human CB1 activation potential. Furthermore, a link with the clinical presentation was appraised. 5F-MDMB-PICA and five metabolites were pharmacologically profiled in vitro, revealing theoretically possible contributions of two active in vivo metabolites to overall cannabinoid activity. Serum concentrations of 5F-MDMB-PICA were correlated to the ex vivo cannabinoid activity, revealing a sigmoidal relationship. The latter could also be predicted based on pharmacological characterization of 5F-MDMB-PICA and its metabolites and an in-depth investigation of the bioassay outcome. Clinically, the GCS showed a significant trend (decrease) with increasing ex vivo cannabinoid activity. This is the first study to evaluate possible toxic effects of 5F-MDMB-PICA in a unique large patient cohort. It allows a better understanding of 5F-MDMB-PICA and metabolites in humans, suggesting a negligible contribution by 5F-MDMB-PICA metabolites to the overall cannabinoid activity in serum. Additionally, this work shows that in vitro pharmacological characterization allows close prediction of an individual's ex vivo CB1 activity, the latter showing a relationship with the level of consciousness. [ABSTRACT FROM AUTHOR]

A letter to the editor of Neurosurgical Review expresses appreciation for a recent article titled "Traumatic Atlantoaxial Rotatory Fixation in Adults: A Systematic Review of Published Cases." The study reviewed the management strategies and clinical presentations of traumatic atlantoaxial rotatory fixation (AARF) in adults. The authors identified 83 patients from 61 articles, with a mean age of 36.1 years. The review found that acutely diagnosed cases are more likely to succeed with conservative treatment, while chronically diagnosed cases usually require surgical treatment. The letter also highlights some methodological points, including the lack of protocol registration, the exclusive use of PubMed as the sole database for literature search, the absence of tools to measure the risk of bias, and the need to update the search to include recent studies. Despite these limitations, the study provides valuable guidance for healthcare professionals. [Extracted from the article]

Background: Currently, no standardized core content in medical toxicology exists for medical students. The goals of this study were to (1) assess the current state and needs of medical toxicology clerkships and (2) develop a consensus-derived list of core topics that should be covered during a medical toxicology clerkship. Methods: We assembled a task force established by the American College of Medical Toxicology (ACMT) of nine experts in medical toxicology or emergency medicine. We developed a needs assessment survey that was sent to all medical student clerkship directors in medical toxicology. Based on their responses, we used a modified Delphi process to develop a consensus of core topics that should be covered during a medical student clerkship. Results: Nineteen out of 42 (45%) clerkship directors completed the survey; 18 met inclusion criteria. The majority of clerkships were 4 weeks in duration with an average of 15 students/year. The three most common teaching methods used were bedside teaching (n = 17/18), classroom teaching (n = 17/18), and journal club (n = 14/18). All the clerkship directors (n = 18/18) reported they would use a standardized curriculum as well as educational content developed by ACMT. There was overwhelming consensus on the core topics which included, but were not limited to, pharmacology/toxicology; drugs; drugs of abuse; natural products; pharmacological basis of antidote use; toxicologic syndromes; vital sign abnormalities; initial management; supportive and other care; withdrawal syndrome management; industrial, household, and environmental toxins; differential diagnosis by clinical findings; and ABCs-resuscitation. Conclusion: The ACMT task force developed a medical toxicology clerkship core content. The task force also identified a need for shared resources among clerkships. [ABSTRACT FROM AUTHOR]

Data on cleaner and disinfectant exposure and misuse-related acute intoxications in Italy during SARS-CoV-2 pandemic are still lacking. The aim of the present study was to analyse and describe cleaner and disinfectant-related intoxications during SARS-CoV-2 pandemic in an Italian poison control centre. Data were obtained from the toxicological consultations requested to the Toxicology Unit and Poison Centre, Careggi University Hospital, Florence (Italy). We compared data from January 1st to April 30th of 2019 and 2020. Data concerning probable or acute intoxication from any causative agent in the general population (all age groups), from private individuals or from Regional and National health structures, were included in the analysis. A toxicological evaluation was also performed to calculate the Poisoning Severity Score. In 2019, 451 phone counselling sessions were performed and compared to a total of 410 calls received during the same period of 2020. In both periods, the majority of events occurred in paediatric (0–17 years) and adult (18–65 years) patients, who were mainly exposed to one toxic agent, and intoxications took place principally at home due to domestic accidents. The oral route of intoxication was the most frequently observed one, followed by inhalation of toxic agents, which increased by 4.7% in 2020. In 2020, sanitizers and cleaners were reported in 21.6% of cases compared to 12.5% in 2019. This is the first study describing cleaner and disinfectant-related intoxications in Italy. Our results suggested a possible misuse of these products during the SARS-CoV-2 pandemic, underling the effects of home isolation on mental health and unintentional toxic exposures. [ABSTRACT FROM AUTHOR]

Unique chemical and physical properties of metal–organic framework (MOF) nanoparticles suggest them as promising candidates for various biomedical applications including drug delivery, biosensor, nitric oxide storage, and contrast agent. Recently, the bioactive MOFs were developed for drug delivery applications through the direct coupling of bioactive linkers such as amino acids, peptides, proteins, nucleobases, and saccharides. However, one of the major concerns with in vivo administration of the carriers is potential toxicity associated with degradation and metabolism of MOFs inside the body. Although toxicological studies of MOFs are still in its beginning stage, some parameters that may induce the toxicity in MOFs are known such as particle size, shape, types of cross-linkers and metals, functional groups, and solvent system. However, degradation mechanism, kinetics, and toxicity of MOF nanoparticles are still under study and further investigations are required to develop rationally designed MOFs with enhanced stability, biocompatibility, and therapeutic efficacy. The future efforts might be focused on the development of stable and biocompatible MOFs using bioactive linkers. This review highlights the recent advances on the synthesis, applications, and toxicity assessments of MOFs. In addition, in vivo and in vitro toxicity studies were briefly discussed with emphasis on currently available toxicology data and the future perspective of their potential clinical applications were evaluated. [ABSTRACT FROM AUTHOR]

The Toxicology Investigators Consortium (ToxIC) Registry was established by the American College of Medical Toxicology in 2010. The registry collects data from participating sites with the agreement that all bedside and telehealth medical toxicology consultation will be entered. This eleventh annual report summarizes the Registry's 2020 data and activity with its additional 6668 cases. Cases were identified for inclusion in this report by a query of the ToxIC database for any case entered from January 1 to December 31, 2020. Detailed data was collected from these cases and aggregated to provide information which included demographics, reason for medical toxicology evaluation, agent and agent class, clinical signs and symptoms, treatments and antidotes administered, mortality, and whether life support was withdrawn. Gender distribution included 50.6% cases in females, 48.4% in males, and 1.0% identifying as transgender. Non-opioid analgesics were the most commonly reported agent class, followed by opioid and antidepressant classes. Acetaminophen was once again the most common agent reported. There were 80 fatalities, comprising 1.2% of all registry cases. Major trends in demographics and exposure characteristics remained similar to past years' reports. Sub-analyses were conducted to describe race and ethnicity demographics and exposures in the registry, telemedicine encounters, and cases related to the COVID-19 pandemic. [ABSTRACT FROM AUTHOR]

Introduction: The American Board of Emergency Medicine identifies medical toxicology as an essential curricular element for emergency medicine (EM) residencies; however, access to medical toxicology education varies widely by institution. We hypothesized that EM residents are uncomfortable with core toxicology content and would be interested in a dedicated toxicology curriculum. Methods: An electronic needs assessment survey developed by experts in EM and medical toxicology was sent to residents and program leadership at nine EM programs participating in the Emergency Medicine Education Research Alliance (EMERA), a geographically diverse sampling of academic EM residency programs. We queried the presence of a current toxicology curriculum, interest in a dedicated toxicology curriculum, and comfort with core toxicology concepts for board examinations and in clinical practice. Results: A total of 148 residents and 8 faculty leadership completed the survey. Only 29% of resident respondents felt comfortable with toxicology concepts, and only 66% of respondents reported access to a toxicology curriculum. Of those without a known toxicology curriculum, most were interested in a formal curriculum. Faculty respondents reported 6/8 programs offered a toxicology curriculum. Faculty at the two programs without a formal curriculum expressed interest in a dedicated curriculum. Conclusions: Emergency medicine residents remain uncomfortable with the core toxicology content in clinical practice. The majority of residents without a known toxicology curriculum would be interested in a dedicated toxicology curriculum. [ABSTRACT FROM AUTHOR]

This trend article reviews papers with hyphenated high-resolution mass spectrometry (HRMS) approaches applied in analytical toxicology, particularly in clinical and forensic toxicology published since 2016 and referenced in PubMed. The article focuses on the question of whether HRMS has or will become the all-in-one device in these fields as supposed by the increasing number of HRMS presentations at scientific meetings, corresponding original papers, and review articles. Typical examples for the different application fields are discussed such as targeted or untargeted drug screening, quantification, drug metabolism studies, and metabolomics approaches. Considering the reviewed papers, HRMS is currently the only technique that fulfills the criteria of an all-in-one device for the various applications needed in analytical toxicology. Graphical abstract [ABSTRACT FROM AUTHOR]

Results: Our results indicated a dose-dependent cytotoxic effect of the essential oil in both cell lines (HT-29 and Caco-2) by decreasing cell viability percentage and inducing changes in cells" shape (round cells) and adherence (floating cells in the culture medium). Using flow cytometry and cell imaging methods, we studied precursors of angiogenesis (CD45CD309+CD117+), endothelial progenitor cells (CD45-CD31+CD34+), VEGF2 + cells, lung stem cells (CD45-CD117+CD49f+) and Clara cells (CD45-CD34-CD31-Sca1+). Material and Methods: We evaluated the effects of a human-relevant organochlorine mixture with known reproductive toxicity in vivo and in vitro on GJIC in murine prepubertal testicular (Leydig Tm3 and Sertoli Tm4) cells using a semi-high throughput cell imaging assay for a simultaneous assessment of GJIC, cell viability and cell density/growth in adherent cultures. Mechanistically, an increased glucose consumption was observed after metformin treatment in non-transformed cells as well as in the mixed population of malignant transformed cell foci and non-transformed monolayer cells, suggesting that metformin could also increase glucose consumption in transformed cells. The comparison between the cytotoxic effect of 5-FU and eucalyptus on fibroblast cells and cancerous SW48 cell line indicated that eucalyptus, by itself, had a significant effect on the cell viability of normal cells such as fibroblast cells, and its cytotoxic effect mildly decreased. [Extracted from the article]

Introduction: Endotracheal intubation (ETI) is an essential component of the supportive care provided to the critically ill patient with pharmaceutical poisoning; however, specific nuances surrounding intubation including techniques and complications in the context of pharmaceutical poisoning have not been well elucidated. Discussion: A search of the available literature on ETI in pharmaceutical-poisoned patients was undertaken using Medline, ERIC, Cochrane database, and PsycINFO using the following MeSH and keyword terms: ("toxicology" OR "poisons" OR "drug overdose" OR "poisoning") AND ("intubation, intratracheal" OR "intubation, endotracheal" OR "airway management" OR "respiration, artificial"). A hand-search was also performed when the literature in the above search required additional conceptual clarification, including using the "Similar Articles" feature of PubMed, along with reviewing articles' reference lists that discussed intubation in the context of a poisoning scenario. Articles with any discussion around the ETI process in the context of a pharmaceutical poisoning were then included. Intubation may be performed in patients poisoned with pharmaceuticals in the context of both single and multiple organ dysfunction including central and peripheral nervous system, pulmonary, or cardiovascular toxicity with hemodynamic instability, or localized effects resulting in mechanical airway obstruction. Certain classes of poisonings may require modifications to the standard rapid sequence induction airway management algorithm. Conclusions: ETI is a key component of the supportive care provided to the patient poisoned by a pharmaceutical agent. Clinicians should be aware of the spectrum of toxicities that can necessitate intubation, as well as airway management nuances that are specific to various poisoning presentations. [ABSTRACT FROM AUTHOR]

Introduction: Worldwide an estimated one million deaths occur annually as a result of poisoning. Internationally there is a lack of toxicology training programs, especially in resource poor settings. We developed a one-day, interactive toxicology curriculum for healthcare practitioners in countries lacking clinical toxicology training and evaluated its feasibility and effectiveness for knowledge dissemination. Methods: GETKIT was developed with 3 sections: didactics, hands on toxicology case lab, and technology clinic. The investigators, who are medical toxicologists,created 23 didactic lectures and 42 workshop cases. All materials were peer reviewed by 5 senior medical toxicologists for content validity. Participants atpilot sites were given pre-course, post-course, and 3-month follow-up tests and surveys. Results: GETKIT was delivered internationally at 7 sites between November 2017 and April 2018. There were 186 total participants. One hundred and ten participants (59%) reported their hospital lacked a clinical toxicology service. The median post course score 12 (60%), IQR (6,14) was significantly higher compared to the pre-course score 9 (45%), IQR (6,11) (p < 0.0001). There was a significantly higher median 3-month post course score 13 (65%), IQR (8,14) vs. a median pre course score of 9 (45%), IQR (6,11) (p 0.0005). At 3-month follow up 86% of participants reported GETKIT had changed their clinical practice. Conclusions: An improvement in and retention of medical toxicology knowledge was demonstrated with the GETKIT course. It also conferred improvement in selfreportedpoisoning management practices in participants from low resource settings. [ABSTRACT FROM AUTHOR]

High-content screening (HCS) technology combining automated microscopy and quantitative image analysis can address biological questions in academia and the pharmaceutical industry. Various HCS experimental applications have been utilized in the research field of in vitro toxicology. In this review, we describe several HCS application approaches used for studying the mechanism of compound toxicity, highlight some challenges faced in the toxicological community, and discuss the future directions of HCS in regards to new models, new reagents, data management, and informatics. Many specialized areas of toxicology including developmental toxicity, genotoxicity, developmental neurotoxicity/neurotoxicity, hepatotoxicity, cardiotoxicity, and nephrotoxicity will be examined. In addition, several newly developed cellular assay models including induced pluripotent stem cells (iPSCs), three-dimensional (3D) cell models, and tissues-on-a-chip will be discussed. New genome-editing technologies (e.g., CRISPR/Cas9), data analyzing tools for imaging, and coupling with high-content assays will be reviewed. Finally, the applications of machine learning to image processing will be explored. These new HCS approaches offer a huge step forward in dissecting biological processes, developing drugs, and making toxicology studies easier. [ABSTRACT FROM AUTHOR]

The correction notice states that there was an error in Table 1 of the original article titled "American College of Medical Toxicology and the American Academy of Clinical Toxicology Position Statement: Nalmefene Should Not Replace Naloxone as the Primary Opioid Antidote at This Time." The error involved the transposition of the Tmax values for naloxone IN and nalmefene IN. The correct Tmax for naloxone IN is 0.5 hours, while the correct Tmax for nalmefene IN is 0.25 hours. The authors and the journal apologize for the error, and the original article has been corrected. [Extracted from the article]

While we agree that confirmation of beta-blocker presence via lab testing is ideal and would provide certainty that a beta-blocker was present in supratherapeutic amounts in the circulation, this was not possible due to the retrospective nature of the case series and beta-blocker concentrations not being routinely obtained in practice as they are generally unavailable for ordering and do not result in "real time" mitigating utility in acute management. The initial concern raised was with respect to terminology (ie, the word "confirmed") utilized to differentiate between those patients for whom we had a higher degree of certainty, although admittedly not absolute, that beta-blockers were ingested versus those in whom beta-blocker ingestion was merely suspected. [Extracted from the article]

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Studying the drugs of natural origin that promote recovery of an organism after acute poisoning with household and industrial toxicants, including organophosphates (OPs), is a challenge not only to toxicology but also informatics, which is a major tool for developing the methodology of system analysis. We report here the data on the effect of decaffeinated green tea extract (GTE) as a pelleted feed component on the dynamics of 12-week recovery of rats after acute paraoxon (POX) poisoning in the models with preliminary specific and nonspecific inhibition of blood plasma carboxylesterase. GTE causes a decrease in atherogenic indices and a positive dynamics in other combinatorial indices due to its effect on levels of hemoglobin, total protein, albumin, triacylglycerides, orosomucoid, and calcium ions as well as on the balance of immune cells. Thereby, GTE is supposed to promote regeneration of an organism after acute POX poisoning. The heuristic algorithm that we proposed previously to derive combinatorial markers by the branch and bound approach was optimized in this study, allowing us to increase the statistical significance of intergroup and/or temporal differences and to form syndromic complexes via clusterization of physiological and biochemical indices. The latter may considerably complement experimental studies conducted on different animal species and ensure more adequate interpretation of the resulting data as applied to humans. [ABSTRACT FROM AUTHOR]

Cardiovascular disease has maintained the unenviable position as the number one cause of death in the world. It is now clear that the traditional risk factors of cardiovascular disease are driven by primary factors like globalisation, urbanisation, industrialisation and agricultural practices. Pesticide use is an integral component of modern and improved agriculture. The abuse and misuse of these chemicals has caused significant poisoning worldwide and particularly in low- and middle-income countries where Africa belongs. This review surveys the widening population of people poisoned by pesticides in Africa and examines the possibility of pesticide-induced cardiotoxicity. The exposed group includes workers in pesticide industries, transporters of these chemicals, farmers, farm workers who apply these pesticides, vendors and sellers of farm produce and consumers of foodstuffs that are treated with pesticides as well as persons who consume water and inhale air filled with pesticides. There are numerous animal model studies that employ electrocardiography, echocardiography, enzyme studies and histopathology to demonstrate pesticide-induced cardiotoxicity in many parts of the world. There are also case reports and epidemiological data of pesticide-induced cardiovascular intoxication in man. With the increasing reports of pesticide-induced central system nervous toxicity in Africa, there are enough reasons to suspect cardiovascular system poisoning as well. The poorly developed clinical toxicology specialty may explain the low index of suspicion of pesticide-induced cardiovascular diseases. With the pervading ignorance, indiscriminate sale, unguarded use, lack of adequate legislation, inadequate enforcement of legal institutes associated with pesticide use in Africa, there is no doubt that the increasing prevalence and incidence of cardiovascular diseases may partly be due to exposure to these chemicals. Africans may after all be at risk of pesticide-induced cardiotoxicity, but more studies will be required to examine the pattern of cardiotoxicity as well as factors that modulate its occurence. [ABSTRACT FROM AUTHOR]

Systematic chemotherapy has required high time span for recovery in cancer patients, serious toxic effects, and increased the time of cancer-free survival of patient but decreased the overall survival time of patients irrespective of diseased condition(s). To compare the quick recovery of inhalable doxorubicin and cisplatin in the lung cancer patients. A total of 240 patients with non-small cell lung cancer (NSCLC) patients were randomly divided into two groups of 120 each. Patients had inhaled 25 mg/m2 doxorubicin (DON group) or 10 mg/m2 cisplatin (CPN group) once in a day for 21 days. Volume, diameter, type, and a number of lung nodes, pulmonary function, and 21-day lung cancer risk assessment were evaluated. One-way ANOVA following Bonferroni multiple comparison tests was performed at 95% of confidence level. DON and CPN both groups had shrunken the lung cancer nodule, decreased solid nodules and non-solid nodules, and increased partially solid nodules. The DON group (5.88 ± 3.98%) had strongly decreased nodule size than the CPN group (4.15 ± 2.92%; p < 0.0001, q = 3.721). The incidence of nodular size reduction was 9.47 ± 1.13% higher for doxorubicin than cisplatin. The CPN group had 36.53 ± 0.66% and the DON group had 34.65 ± 0.7% lung cancer risk assessment after 21 days (p < 0.0001, q = 3.785). Inhalable doxorubicin might be an effective therapy in NSCLC patients with acceptable hematologic and non-hematologic toxic effects. Trial Registry: researchregistry3382, dated 28 December 2014 (www.researchregistry.com). [ABSTRACT FROM AUTHOR]

Purpose: Gamma-hydroxybutyrate (GHB) withdrawal is a life-threatening condition that does not always respond to standard treatment with benzodiazepines. Baclofen has potential utility as a pharmacological adjunct and anecdotal reports suggest that it is being used by drug users to self-manage GHB withdrawal symptoms. Here, we investigate current patterns of use and the online availably of baclofen.Methods: Data triangulation techniques were applied to published scientific literature and publicly accessible Internet resources (grey literature) to assess the use of baclofen in GHB withdrawal. An Internet snapshot survey was performed to identify the availability of baclofen for online purchase and the compliance of retailers with the UK regulations. Data were collected according to pre-defined criteria.Results: A total of 37 cases of baclofen use in GHB withdrawal were identified in the scientific literature, as well as 51 relevant discussion threads across eight Internet forums in the grey literature. Baclofen was available to purchase from 38 online pharmacies, of which only one conformed to the UK regulations.Conclusions: There is limited published evidence on the use of baclofen in GHB withdrawal, but both scientific and grey literature suggests clinical utility. Online pharmacies are readily offering prescription-only-medication without prescription and due to inadequate regulation, pose a danger to the public. [ABSTRACT FROM AUTHOR]