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As per the World Health Organization, a disaster is defined as “an event that occurs in most cases suddenly and unexpectedly, causing severe disturbances to people or objects affected by it, resulting in the loss of life and harm to the health of the population.” A number of health issues are often reported following disasters, such as physical and psychological trauma, infections, malnutrition, and cardiovascular events. Among these, venous thromboembolism is deemed serious and thus should be taken into consideration. Indeed, its risk has been demonstrated to increase following earthquakes, floods, burns, and intoxications. The recent coronavirus pandemic summarizes some of the main triggering factors involved in acute and chronic venous disease development in a disaster setting: inflammation, infection, lockdown-induced reduced mobility, potential malnutrition, and overweight. Proper venous risk assessment and guideline application have been determined to be essential in disaster management, particularly in the current time in which sheltering could lead to a potential exacerbation of the pandemic, which can only increase the risk for venous thrombotic diseases. Global scientific teamwork is needed to make the recommendations as evidence-based and as homogeneous as possible among continents. In this present review, we focus on how earthquakes impact venous thromboembolism, including an analysis of other disaster-related conditions, such as burns and intoxication. (This is a review article based on the informative seminar of the 40th Annual Meeting of Japanese Society of Phlebology.)

Intoxication with tricyclic antidepressant drugs causes serious toxic findings even at low doses. Despite common use of the antidepressant drugs, there are no randomized controlled trials about treatments in tricyclic antidepressant drug intoxication. Here we report a 23-month-old girl admitted to the emergency room with status epilepticus. We diagnosed that she had ingested toxic amount of amitriptillin. Since the patient’s clinical status deteriorated despite conventional treatments (lidocaine, epinephrine, norepinephrine, magnesium sulphate, sodium bicarbonate, activated charcoal), we administered intravenous lipid emulsion and treated the patient successfully.

Carbon disulfide (CS2) is a colorless oily liquid with an original smell, which reminds chloroform. It is very toxic. Carbon disulfide is widely applied in manufacture of viscose fibres, cellophane, in the chemical industry — as solvent of phosphorus, fats, rubbers, in the agriculture — as insecticide. It enters the body through respiratory ways and skin. Carbon disulfide belongs to neurotoxic poisons, which affects mainly the higher departments of the central nervous system and peripheral nervous system. Carbon disulfide can cause acute and chronic intoxications. For acute poisonings by carbon disulfide, rapid development of semiology is typical. In terms of a degree of manifestations, there are mild, moderate and severe forms of acute carbon disulfide poisonings. It is characterized mainly by symptoms according to the type of intoxication, which gradually becomes a narcosis. In terms of clinical course, there are 3 stages of chronic intoxication: functional (carbon disulfide neurosis), initial organic changes, organic (toxic encephalopathy and polyneuritis). In cases of acute intoxication, the victim should be immediately taken out from the danger area into the fresh air. It is necessary to create conditions of rest, to give strong tea, coffee. There are no specific antidotes. Symptomatic treatment is carried out according to clinical manifestations of disease. Oxygen therapy (15 minutes — carbogen, 45 minutes — oxygen) to be performed. Stimulants of the heart and respiratory center are introduced. In chronic intoxication, intravenous infusions of 40% glucose solution (20 ml), the use of vitamin B6, glutamic acid, copper sulfate or acetate for 3–4 weeks are effective. Patients with toxic encephalopathy should take tranquilizers, antidepressants. Oxygen therapy and physiotherapeutic methods of treatment are also used (galvanic stimulation of the collar zone, carbonic baths)., Сероуглерод (CS2) — бесцветная маслянистая жидкость со своеобразным запахом, который напоминает хлороформ. Очень токсичный. Сероуглерод широко применяется в производстве вискозных волокон, целлофана, в химической промышленности — как растворитель фосфора, жиров, резины, в сельском хозяйстве — как инсектицид. В организм поступает через дыхательные пути и кожу. Сероуглерод принадлежит к нейротропным ядам, которые поражают преимущественно высшие отделы центральной нервной системы и периферическую нервную систему. Сероуглерод может вызвать острые и хронические интоксикации. Для острых отравлений сероуглеродом характерно бурное развитие симптоматики. По степени проявлений различают легкие, средней тяжести и тяжелые формы острых отравлений сероуглеродом. Характеризуется в основном симптоматикой по типу опьянения, которое плавно переходит в наркоз. Хроническую интоксикацию по клиническому течению подразделяют на 3 стадии: функциональную (сероуглеродный невроз); начальных органических изменений; органическую (токсическая энцефалопатия и полиневрит). В случаях острой интоксикации потерпевшего следует немедленно вынести (вывести) из опасной зоны на свежий воздух. Необходимо обеспечить покой, дать крепкий чай, кофе. Специфических антидотов нет. Проводят симпто­матическое лечение в соответствии с клиническими проявлениями заболевания. Показана оксигенотерапия (15 минут — карбоген, 45 минут — кислород). Вводят стимуляторы деятельности сердца и дыхательного центра. При хронической интоксикации эффективны внутривенные вливания 40% раствора глюкозы (20 мл), применение витамина В6, глутаминовой кислоты, меди сульфата или ацетата на протяжении 3–4 недель. Больным с токсической энцефалопатией показаны транквилизаторы, антидепрессанты. Применяются также оксигенотерапия и физиотерапевтические методы лечения (гальванизация воротниковой зоны, углекислые ванны)., Сірковуглець (CS2) — безбарвна масляниста рідина зі своєрідним запахом, що нагадує хлороформ. Дуже токсичний. Сірковуглець широко застосовується у виробництві віскозних волокон, целофану, у хімічній промисловості — як розчинник фосфору, жирів, гуми, у сільському господарстві — як інсектицид. В організм надходить через дихальні шляхи й шкіру. Сірковуглець належить до нейротропних отрут, що уражають переважно вищі відділи центральної нервової системи й периферичну нервову систему. Сірковуглець може викликати гострі й хронічні інтоксикації. Для гострих отруєнь сірковуглецем характерний бурхливий розвиток симптоматики. За ступенем проявів розрізняють легкі, середньої тяжкості й тяжкі форми гострих отруєнь сірковуглецем. Характеризується в основному симптоматикою за типом сп’яніння, що плавно переходить у наркоз. Хронічну інтоксикацію за клінічним перебігом поділяють на 3 стадії: функціональну (сірковуглецевий невроз); початкових органічних змін; органічну (токсична енцефалопатія і поліневрит). У випадках гострої інтоксикації потерпілого слід негайно винести (вивести) з небезпечної зони на свіже повітря. Необхідно забезпечити спокій, дати міцний чай, каву. Специфічних антидотів немає. Проводять симптоматичне лікування відповідно до клінічних проявів захворювання. Показана оксигенотерапія (15 хвилин — карбоген, 45 хвилин — кисень). Вводять стимулятори діяльності серця й дихального центру. При хронічній інтоксикації ефективні внутрішньовенні вливання 40% розчину глюкози (20 мл), застосування вітаміну В6, глутамінової кислоти, міді сульфату або ацетату протягом 3–4 тижнів. Хворим із токсичною енцефалопатією показані транквілізатори, антидепресанти. Застосовуються також оксигенотерапія і фізіотерапевтичні методи лікування (гальванізація комірцевої зони, вуглекислі ванни).

Introduction Bicycles and electric scooters (e-scooters) are convenient and accessible means of transportation. Participant safety is contingent on available infrastructure and safe riding practices including not riding while intoxicated. Understanding national prevalence and injury characteristics of bicycle and e-scooter riders who ride while intoxicated may promote awareness campaigns for safe riding practices and decrease morbidity. Methods The National Electronic Injury Surveillance System (NEISS) provides national estimates of injuries that present to emergency departments across the United States. We obtained case information on admitting status, body part injured, diagnosis of injury, age, sex, alcohol usage, and drug usage. We then queried NEISS for injuries related to bicycles and e-scooters in 2019. Results A weighted total of 270,571 (95% confidence interval (CI): 204,517–336,625) bicycle injuries occurred in the United States during 2019; alcohol and drug use were associated with 7% (95% CI: 6–9) and 2% (95% CI: 2–3) of all injuries, respectively. Twenty-four percent (CI: 18--31) of alcohol- and 29% (95% CI: 20–41) of drug-related bicycle injuries resulted in hospital admissions, compared to 15% (95% CI: 12–17) of non–alcohol- and 15% (95% CI: 13–18) of non–drug-related injuries ( p < .001 and p = .002, respectively). A total of 28,702 (95% CI: 13,975–43,428) e-scooter injuries occurred in 2019; alcohol and drug use were associated with 8% (95% CI: 5–12) and 1% (95% CI: 1–2) of injuries, respectively. Sixty percent (95% CI: 47–72) of alcohol-related e-scooter injuries resulted in head trauma, compared to 28% (95% CI: 24–32) of non–alcohol-related injuries ( p < .001). Conclusions Intoxication is associated with increasingly severe injuries, hospital admissions, and head trauma in bicycle and e-scooter riders. The findings support awareness campaigns to educate riders about risky practices, improve non-auto infrastructure, and promote helmet usage.

Background Severe venlafaxine intoxication may cause arrhythmias, cardiac failure, and even cardiac arrest. Case presentation A 48-year-old caucasian male with an extensive psychiatric history ingested a high dose of venlafaxine causing a serum venlafaxine concentration of 12.6 mg/L 24 hours after ingestion. Seven hours post-ingestion, he experienced tonic–clonic seizures, and 8 hours later, takotsubo cardiomyopathy was recognized followed by cardiac arrest. The patient was resuscitated with prolonged cardiopulmonary resuscitation including ongoing automatic external compressions during helicopter transportation to a tertiary hospital for extracorporeal membrane oxygenation treatment. Despite a cardiopulmonary resuscitation duration of 2 hours, 36 hours of extracorporeal membrane oxygenation, and a total of 30 days of intensive care, the patient made a full recovery. Conclusion In cases of intoxication-induced cardiac arrests among otherwise young and healthy patients, prolonged cardiopulmonary resuscitation and extracorporeal circulation can be a life-saving bridge to recovery.

International audience; Objective The objectives of this study were to describe poisonings occurring in older or disabled patients residing in structured living facilities, identify risk factors, and propose preventive measures. Method This was a prospective and observational study, covering all cases of poisoning occurring in structured living facilities in the Brittany region of France. All calls were received at the Grand Ouest Poison Control Centre (PCC) of Angers and were recorded from 1 February 2019 to 31 January 2020. The clinical severity of the poisonings was assessed using the Poisoning Severity Score (PSS). Clinical severity was compared by univariate and multivariate analyses using the following dependent variables: PSS score < 2 and PSS >= 2. Results This study included 158 residents with a median age of 83 years (5-116 years old). The average number of residents supervised by a member of the supervisory staff was 11 (+/-10.7). The substance ingested was a personal hygiene product or a cleaning product in 48% and 25% of cases, respectively. The most frequently ingested product was a bar of soap (n = 20). All moderate to severe cases (4.6%, n = 8 including one death) occurred in residents with dementia living in nursing homes for elderly patients, and 9% of residents required hospital treatment. In more than 50% of cases (n = 83), the product was provided by the facility and in 23% (n = 40), it was brought in by the family. Ingestion of a bar of soap or a product brought in by the family was significantly associated with higher poisoning severity (PSS >= 2). After adjustment for age, sex and the number of residents per supervisor, the severity of poisoning was significantly greater after ingestion of a bar of soap (OR = 12.33, CI95 [2.12, 71.63], p = 0.005). Conclusion Older adults residing in medical facilities who have a history of dementia and/or cognitive impairment are more at risk of non-medicinal product poisoning. Clinical severity and the hospitalisation rate were greater when bar soap was ingested.

Introduction:The causes of intoxication can vary from country to country, from region to region within the same country and even in the same region over the years. In this study, the patients with intoxication diagnosis were evaluated in terms of their demographic characteristics, intoxication reasons and also the factors causing intensive care hospitalization in our pediatric intensive care unit (PICU).Methods:The study included 115 patients with intoxication diagnosis between one month and 18 years of age, who were followed up in PICU between January 2017 and December 2019.Results:The median age of the patients was 154 (interquartile range, 37-196) months and 51 patients (44%) were male. The median age of female patients and the patients who were hospitalized due to suicide attempt were higher (p

A 53-year old male with a history of progressive visual impairment, hearing loss, peripheral neuropathy, poorly controlled diabetes mellitus, cardiomyopathy, and weight loss was referred to the rare disease center due to the suspicion of mitochondrial cytopathy. In line with mitochondrial dysfunction, lactate in CSF was increased. Genetic testing by whole-exome sequencing and mitochondrial DNA did not reveal a likely cause. The case remained unsolved until he developed pain in his right hip, where he had received total hip arthroplasty 12 years earlier. An orthopedic evaluation revealed substantial shrinkage of the head of the hip prosthesis. Due to metal-on-metal wear, debris chromium and cobalt levels in serum were massively increased and significantly improved with multisystemic impairment after exchanging the defective implant.

International audience; Background The recreational use of new psychoactive substances (NPS) is increasing worldwide. Among them, the arylcyclohexylamine family including phencyclidine (PCP) and ketamine derivatives is increasing. We report a non-fatal intoxication mainly due to arylcyclohexylamine compounds illustrated by molecular networking (MN). Case details A 37-year-old man with a history of drug abuse was discovered with several bags labeled as research chemicals around him and traces of powder on his nose. He was rehydrated, intubated, and admitted to the intensive care unit (ICU). Urine and drug were analyzed by liquid chromatography-mass spectrometry for NPS identification. Several NPS were quantified in urine: 3-OH-PCP at 12,085 mg/L, 3-MeO-PCP at 1100 mg/L, 2F-DCK at 147 mg/L, N-ethylhexedrone at 165 mg/L and CMC at 48 mg/L. Using a bioinformatic approach, a molecular network was built to confirm the consumption of powders contained in the bags by comparison with patient's urine. Discussion This case illustrates the interest of MN to (i) perform sample-to-sample comparison, (ii) target quantification methods, and (iii) allow proper management to confirm the relevance of the treatment.

Background: Poisoning causes significant morbidity and sometimes mortality in children worldwide. The clinical skill of toxidrome recognition followed by the timely administration of an antidote specific for the poison is essential for the management of children with suspected poisoning. This is a narrative review on antidotes for toxidromes in paediatric practice. Methods: A literature search was conducted on PubMed with the keywords “antidote”, “poisoning”, “intoxication”, “children” and “pediatric”. The search was customized by applying the appropriate filters (species: humans; age: birth to 18 years) to obtain the most relevant articles for this review article. Results: Toxidrome recognition may offer a rapid guide to possible toxicology diagnosis such that the specific antidote can be administered in a timely manner. This article summarizes toxidromes and their respective antidotes in paediatric poisoning, with an emphasis on the symptomatology and source of exposure. The antidote and specific management for each toxidrome are discussed. Antidotes are only available for a limited number of poisons responsible for intoxication. Antidotes for common poisonings include N-acetyl cysteine for paracetamol and sodium thiosulphate for poisoning by cyanide. Conclusion: Poisoning is a common cause of paediatric injury. Physicians should be familiar with the recognition of common toxidromes and promptly use specific antidotes for the management of childhood toxidromes.

Introduction The aim of this study was to investigate the effects of vitamin C (vit C) and magnesium L-threonate (MgT) on the learning ability and memory of mice intoxicated with lead acetate. Material and Methods The experimental male Swiss albinos were divided into five groups of 10 during a 40-day treatment period. One group were untreated controls, one received lead acetate at 90 mg/kg b.w., one additionally vit C at 40 mg/kg b.w., another additionally MgT at 100 mg/kg b.w., and the last was administered MgT without lead acetate. After a 20-day washout period, the animals were trained in the Morris water maze test for 6 days and after a 24-hour interval, were assessed for memory in the same test. At test end the mice were sacrificed and their organs sampled. Results The results of total time and number of entries into the platform zone showed that significantly poorer performances were recorded for the group poisoned with lead acetate alone and significantly lower scores for learning and memory were recorded for the intoxicated and supplemented groups compared to the control group. Catalase activity was significantly reduced in the liver, pancreas and kidney but significantly potentiated in brain tissue by these two supplements compared to the control group. Lead concentration in brain tissue was significantly higher in the presence of vit C than in the control or lead acetate-only groups. Conclusion Lead acetate had adverse effects on learning and memory of mice and also increased catalase activity.

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.

The aim of the study: to assess the lung histopathology in acute intoxication with baclofen alone and its combination with alcohol (in the same dose) 3 hours after the ingestion.Materials and methods. The study was performed on 15 male Wistar rats weighing 290-350 g and aged 20 weeks. The animals were divided into 3 groups, 5 animals each: control group that included intact rats; Group 1 composed of rats received baclofen alone; Group 2 that included rats received a combination of baclofen and ethanol. Baclofen was administered orally at a dose of 85 mg/kg animal weight under anesthesia (chloralose), and 40% ethanol, 7 ml/kg animal weight, was orally administered along with baclofen at the same dose. Animals of all groups were sacrificed after 3 hours by overdosing anesthetic agent. Lung tissue samples were examined by light microscopy using a video system at x400 magnification. The following histological characteristics were evaluated: circulatory disorders (engorged capillaries and venules, hemorrhages in interalveolar septa and alveoli, sludge), atelectasis (including partial), emphysema, cellular response (increased WBCs in the interalveolar septal area), thickening of interalveolar septa due to edema, epithelial desquamation into bronchial lumen. The diameter of alveoli and thickness of interalveolar septa were measured.Results. Three hours after the baclofen administration, circulatory disorders in the lungs (engorged venules and capillaries, hemorrhages in the interalveolar septa, sludge), emphysema, atelectasis (complete and partial) as well as cellular response (leucocyte infiltration of interalveolar septa) were detected. In the Group 2, baclofen resulted in circulatory disorders (engorged venules and capillaries, sludge), emphysema, atelectasis (complete and incomplete), cellular response (infiltration with leukocytes), as well as fluid in the lumen of bronchioles. In Group 1, the alveolar diameter was significantly larger than in the control group and Group 2, while the thickness of the interalveolar septa was lower. In group 2, alveolar diameter was significantly less than in group 1, but still greater than in the control group. The thickness of the interalveolar septa in group 2 was significantly greater than in the control group and group 1.Conclusion. After administration of baclofen alone and in combination with ethanol, the following alterations were found in the lungs: circulation disorders (venular and capillary engorgement, sludge), increased vascular permeability because of developing hypoxia, leukocyte infiltration of interalveolar septa. The monitoring of morphological alterations may aid in evaluating the severity of pathological processes in intoxication with baclofen alone and in combination with ethanol and in determining the method of intoxication (baclofen alone or in combination with ethanol).

Introduction: Childhood intoxications are among the most common reasons for admission to the emergency department. The aim of this study is to evaluate whether there is a primary marker that can determine the risk of arrhythmia by comparison of QT, QTc, QT/QTc, Tp-e/QT, Tp-e/QTc intervals in drug intoxications with prolonging QTc which can be fatal by causing arrhythmia in children. Materials and Methods: In this study, 55 patients who were admitted to Pediatric Emergency Department of Training and Research Hospital between January 2018 and August 2019 within the first 6 hours due to intoxication with QTc prolongation and followed up in our pediatric emergency department were retrospectively reviewed. In patients hospital records, age, sex, medication, time of application, clinical and physical examination findings, vital signs, treatments and results, laboratory findings, electrocardiogram findings at the time of admission hospital and in the 6. hour control, QT, QTc, Tp-e, Tp-e/QT and Tp-e/QTc times were recorded. Results: The median age of the patients in study was 155±77.2 months. The number of female patients was 33 (60%) and the number of male patients was 22. There was a statistically significant difference between leukocyte count, hemoglobin, platelet,bun, creatinine, SGPT and calcium values at the time of admission and control at the 6th hour. There was no statistically significant difference between CK-MB and troponin levels. Also, there was no statistically significant difference between QT, QTc, QT/QTc, Tp-e/QT and Tp-e/QTc intervals. But there was a statistically significant difference between Tp-e/QTc ratio and gender. Conclusions: Although QTc interval continues to be used to determine the risk of arrhythmia in children with drugs prolonging QTc, it may be significant to compare Tp-e and Tp-e/QTc ratio. However, studies involving a larger number of patients are needed to determine whether Tp-e interval and Tp-e/QTc ratio are a priority marker. Giriş: Çocukluk çağı zehirlenmeleri sık görülen acile başvuru nedenleri arasındadır. Bu çalışmada amacımız aritmiye neden olarak ölümcül olabilecek QTc uzaması yapan ilaçlarla zehirlenmelerde QT, QTc, QT/QTc, Tp-e/QT, Tp-e/ QTc oranlarını karşılaştırarak çocuklarda aritmi riskini belirleyebilecek öncelikli bir belirteç olup olmadığını değerlendirmektir. Gereç ve Yöntem: Çalışmamızda Ocak 2018 ve Ağustos 2019 tarihleri arasında Eğitim ve Araştırma Hastanesi Çocuk Acil servisine QTc uzaması yapan ilaçlarla zehirlenme nedeniyle ilk 6 saat içerisinde başvuran ve çocuk acilimizde takip edilen 55 hastanın dosyası retrospektif olarak incelenmiştir. Hasta dosyalarından yaş, cinsiyet, aldığı ilaç, müracaat süresi, klinik bulgu ve fizik muayene bulgusu,vital bulgular, yapılan tedavi ve sonuçları laboratuar bulguları ve başvuru anı ve kontrol bakılan 6. saat EKG (elektrokardiyografi) bulguları, QT, QTc, Tp-e, Tp-e/QT ve Tp-e/QTc süreleri kaydedilmiştir. Bulgular: Çalışmaya alınan hastaların yaş ortancası 155±77,2 ay idi. Kız hasta sayısı 33(%60), erkek hasta sayısı 22 (%40) idi. Çalışmamızda hastaların başvuru anı ve 6. saatte bakılan lökosit sayısı, hemoglobin, platelet, bun, kreatinin, SGPT ve kalsiyum değerleri arasında istatistiksel olarak anlamlı farklılık saptandı (p0,05).EKG’lerinde QT, QTc, QT/QTc, Tp-e/QT ve Tp-e/QTc süreleri arasında istatistiksel olarak anlamlı fark saptanmadı (p>0,05). Tp-e/QTc süreleri ve cinsiyet arasında istatistiksel olarak anlamlı bir farklılık mevcuttu (p

Background Disproportionate fear of contracting COVID‐19 (coronaphobia) may result in inappropriate use of preventive measures that could, in turn, result in severe harm to the patient. Objective To describe a patient with subacute parkinsonism and cognitive dysfunction and magnetic resonance imaging (MRI) evidence of bilateral deep white matter and basal ganglia damage. Case presentation A 56‐year‐old female presented with a 4‐week history of insomnia, cognitive decline, and parkinsonism. Brain MRI revealed a bilateral lesion of both globus pallidus, deep white matter, and cerebellar hemispheres. Her son reported that, for the previous month, she had been cleaning her facial mask three times a day with a pure methanol solution as a disinfectant due to an intense fear of acquiring COVID‐19. Previously, she had used 97% isopropyl alcohol and had inadvertently switched to methanol. After the exposure ended, she slowly improved but 4 months later she remains severely disabled. Conclusions The repeated exposure to methanol vapor, the MRI findings, and the absence of other etiologies for her cognitive and parkinsonian features led to the diagnosis of chronic methanol intoxication with severe central nervous system damage. Misinformation is a likely contributory factor to such scenario. Efforts should be made by the scientific community to educate the general public on avoiding self‐damaging behaviors as a result of coronaphobia., Disproportionate fear of contracting COVID‐19 (coronaphobia) may result in inappropriate use of preventive measures that may in turn result in severe harm to an individual. A patient is described who developed bilateral basal ganglia damage after repeatedly cleaning her face mask with methanol, resulting in severe intoxication.

Caffeine is well known for its central nervous system–stimulating effect. Toxicity may occur following high-dose caffeine ingestions. We describe a case of caffeine intoxication secondary to reported ingestion of a large dose of caffeine (60,000 mg in tablet form) with an initial serum caffeine level of 608 μmol/L (known lethal serum level starting from 412 μmol/L). This case demonstrates the key clinical manifestations of caffeine intoxication and the effect of its associated massive adrenergic surge with neurologic symptoms, cardiovascular instability, metabolic abnormalities, and the significant risk of mortality. We highlight important kidney management considerations, including protective measures against electrolyte disturbances such as hypokalemia and hypophosphatemia, and the use of prolonged hemodialysis for caffeine elimination. We share our practical decision making and approach to dialysis discontinuation if serum caffeine level reporting is unavailable or delayed.

Graphical abstract Saudi poison control centers received 20,513 poisoning consultations calls in the year 2020., Highlights • Saudi poison control centers received 20,513 poisoning consultations calls in the year 2020. • Most of calls were from Riyadh City, less than 6 years old. • The majority of toxic exposures were accidental oral poisoning requesting help within one hour from poisons exposure. • Household substances toxic exposure represented about one third of toxic cases. • We recommended widespread awareness of the poisons risk. • The significant role of poison control centers that play in time management and saving lives in poisoning cases., Introduction Saudi poison control centers provide surveillance data that should be used to determine the magnitude of poisoning exposures and the level of public awareness that is to evaluate control measures. This work aimed to review and assess the characteristics of toxic events received by toxicological information center's hotline all over Saudi Arabia during 2020. Patients and Methods Data were collected from the poison control centers in Saudi Arabia. Cases of poisonings were studied during the period from 1st January to 31st December 2020. Results and Discussion The poison control center received 20,513 calls in the year 2020. Most of calls were from Riyadh city (40.9 %) and from public places (92.9 %). Regarding the patients, most of the cases were less than 6 years old and more than half of them were males. The majority of toxic exposures were accidental oral poisoning. About 84 % of patients (84.3 %) called for help within one hour from poisons exposure. Household substances toxic exposure represented about one third of toxic cases. Chemicals and alcohol sanitizers' poisoning were the highest among house hold substances toxicities (39.3 % and 17.7 % respectively of all household substances toxicity). In addition, the most frequently ingested drugs were vitamins poisoning. Conclusion Household chemicals represented the highest risk in exposures among children below 6 years. Finally, we recommended widespread awareness of the poisons risk and the importance of poison control that play a great role in time management and saving lives.

In recent years, intravenous lipid emulsion therapy (ILE) was used for lipophilic drug intoxications, and successful results were obtained. In the literature, there is a small number of reported cases about verapamil intoxication and ILE therapy in the pediatric age group. We used ILE therapy in a 14-year-old girl with verapamil intoxication in the 2nd h of the pediatric intensive care unit stay, before using traditional treatments such as glucagon and hyperinsulinemic euglycemia. She had resistant bradycardia and hypotension which was unresponsive to inotropic agents and a successful result was obtained after using ILE treatment. We believe our report may contribute to the early use of ILE therapy for toxicity with calcium channel blockers such as verapamil in pediatric patients.

Objectives Paracetamol intoxication is one of the causes of elevated procalcitonin concentrations unrelated to infection. We report a case series of two patients intoxicated with paracetamol whose laboratory data revealed a significant elevation of serum procalcitonin concentrations without clinical, radiological and/or biological evidence of infection. The underlying mechanism by which paracetamol triggers an increase in procalcitonin concentrations is still unclear. Case presentation We report two cases of paracetamol intoxication. Both patients were admitted to the Emergency Department (ED) and subsequently transferred to the Intensive Care Unit (ICU). The patients exhibited elevated procalcitonin levels during the first hours of admission without clinical and/or microbiological evidence of infection that could explain such increase. Notably, only Case 1 developed liver injury, with alterations in alanine aminotransferase (ALT), aspartate aminotransferase (AST), bilirubin and esterified bilirubin concentrations, which were not observed in Case 2. Conclusions The two patients showed elevated procalcitonin concentrations resulting from paracetamol intoxication, although only a patient exhibited signs of liver injury. These findings suggest that increased procalcitonin levels induced by a paracetamol overdose cannot be fully explained by hepatocyte injury alone, but other mechanisms involving other organs and tissues may also be associated. In any case, although this mechanism is not well understood, it is important to be aware of this limitation when using procalcitonin as a biomarker of infection in patients intoxicated with paracetamol.

Traditionally, Star Anise has been used as an antispasmodic in the form of home infusions for the treatment of newborn colic. The objective of this study was to identify the most frequent symptoms of intoxication due to the administration of star anise infusion in pediatric patients. A literature search was performed to identify published reports regarding star anise poisoning in the MEDLINE, PubMed, and Google Scholar databases. 137 cases of star anise intoxication were detected for the period 2014-2019 in which it was found that star anise intoxication has neurotoxic, hepatotoxic, gastrointestinal toxicity and inducer of hypersensitivity reactions.

Supplemental Digital Content is available in the text., Background Acute alcohol intoxication is very common in patients with severe traumatic brain injury (TBI). Whether there is an independent association between alcohol intoxication and mortality is debated. This study hypothesized that alcohol intoxication is independently associated with less mortality after severe TBI (sTBI). Methods This retrospective observational cohort study included all patients with sTBI [head-Abbreviated Injury Score (AIS) ≥3, corresponding to serious head injury or worse] admitted from 1 January 2011 to 31 December 2016 in an academic level I trauma center. Patients were classified as with alcohol intoxication or without intoxication based on blood alcohol concentration or description of alcohol intoxication on admission. The primary endpoint was in-hospital mortality. Multivariable logistic regression analysis, including patient and injury characteristics, was used to assess independent association with alcohol intoxication. Results Of the 2865 TBI patients, 715 (25%) suffered from alcohol intoxication. They were younger (mean age 46 vs. 68 years), more often male (80 vs. 57%) and had a lower median Glasgow Coma Scale upon arrival (14 vs. 15) compared to the no-intoxication group. There was no difference in injury severity by head AIS or Rotterdam CT. Alcohol intoxication had an unadjusted association with in-hospital mortality [unadjusted odds ratio (OR) 0.51; 95% confidence interval (CI), 0.38–0.68]; however, there was no independent association after adjusting for potentially confounding patient and injury characteristics (adjusted OR 0.72; 95% CI, 0.48–1.09). Conclusion In this retrospective study, there was no independent association between alcohol intoxication and higher in-hospital mortality in emergency patients with sTBI.

PubMed: 33009763 INTRODUCTION: A smokeless tobacco known as Maras powder (MP) is commonly consumed in the southern region of Turkey. To the extent of our knowledge, no previous study in literature has reported acute MP intoxication in children. AIM: Our aim was to determine the clinical effects and treatment strategies of MP poisoning in children.Materials and methods: We retrospectively reviewed the medical records of children

The material of this case consisted of a 3,5 kg male Chinchilla cat which brought to Selcuk University Veterinary Faculty Animal Hospital with the complaints of anorexia, stagnation, incoordination, watery diarrhea and severe vomiting. Mushroom intoxications suspected according to the anamnesis. False morel poisoning was diagnosed as a result of physical examination and laboratory test and it was confirmed by presence of ingested spore of morel in fecal flotation examination. As a treatment, 0.9% isotonic NaCl (Polyplex, Polifarma ® ) solutions 40 ml/kg via IV, maropitant (Cerenia, Zoetis ® ) 1 mg/kg as an antiemetic and to reduce visceral pain via SC, N-acetylcystein (Nacosel, Haver Farma ® ) 140 mg/kg via IV, vitamins and amino acid supplementation (Duphalyte, Zoetis ® ) via IV are administered. For liver health supplementation SAMe and silybin (Denamarin, Nutramax ® ) 15 mg/kg via PO for 21 days prescribed. On re-examination, the cat was fully recovered. It was concluded that false morel poisoning may cause liver damage, neurologic findings along with the primary gastrointestinal system disorders. Anamnesis, presence of the ingested spore of morel observed during fecal examination is very important in the diagnosis and the prognosis is affected by the magnitude of liver damage.

Background: Basal ganglia lesions are typical findings on magnetic resonance imaging (MRI) of the brain in survivors of acute methanol poisoning. However, no data are available on the association between the magnitude of damaged brain regions, serum concentrations of markers of acute methanol toxicity, oxidative stress, neuroinflammation, and the rate of retinal nerve ganglion cell loss., Objectives: To investigate the association between MRI-based volumetry of the basal ganglia, retinal nerve fibre layer (RNFL) thickness and prognostic laboratory markers of outcomes in acute methanol poisoning., Methods: MRI-based volumetry of putamen, nucleus caudatus and globus pallidus was performed and compared with laboratory parameters of severity of poisoning and acute serum markers of oxidative damage of lipids (8-isoprostan, MDA, HHE, HNE), nucleic acids (8-OHdG, 8 - OHG, 5 - OHMU), proteins (o-Thyr, NO-Thyr, Cl-Thyr) and leukotrienes (LTC4, LTD4, LTE4, LTB4), as well as with the results of RNFL measurements by optic coherence tomography (OCT) in 16 patients with acute methanol poisoning (Group I) and in 28 survivors of poisoning two years after discharge with the same markers measured within the follow-up examination (Group II). The control group consisted of 28 healthy subjects without methanol poisoning., Results: The survivors of acute methanol poisoning had significantly lower volumes of basal ganglia than the controls. The patients with MRI signs of methanol-induced toxic brain damage had significantly lower volumes of basal ganglia than those without these signs. A positive correlation was found between the volume of putamen and arterial blood pH on admission (r = 0.45; p = 0.02 and r = 0.44; p = 0.02 for left and right putamen, correspondingly). A negative correlation was present between the volumes of putamen and acute serum lactate (r = -0.63; p < 0.001 and r = -0.59; p = 0.01), creatinine (r = -0.53; p = 0.01 and r = -0.47; p = 0.01) and glucose (r = -0.55; p < 0.001 and r = -0.50; p = 0.01) concentrations., The volume of basal ganglia positively correlated with acute concentrations of markers of lipoperoxidation (8-isoprostan: r = 0.61; p < 0.05 and r = 0.59; p < 0.05 for left and right putamen, correspondingly) and inflammation (leukotriene LTB4: r = 0.61; p < 0.05 and r = 0.61; p < 0.05 for left and right putamen, correspondingly). The higher the volume of the basal ganglia, the higher the thickness of the RNFL, with the strongest positive association between global RNFL and the volume of putamen bilaterally (all p < 0.01). In the follow-up markers of oxidative stress and inflammation, only o-Thyr concentration negatively correlated with the volume of putamen bilaterally (r = -0.39; p < 0.05 and r = -0.37; p < 0.05 for left and right putamen, correspondingly)., Conclusion: In survivors of acute methanol poisoning with signs of toxic brain damage, the magnitude of affected areas correlated with acute parameters of severity of poisoning, markers of oxidative stress and neuroinflammation. There was a positive association between the basal ganglia volume and the thickness of RNFL, making OCT an important screening test and MRI-based volumetry the confirmative diagnostic method for the detection of CNS sequelae of methanol poisoning.

Background 3,4-Methylenedioxymethamphetamine intoxication can result in potentially lethal multi-organ failure, for which the current treatment is largely supportive. Recently, a report of the use of the CytoSorb device as a part of the successful treatment of a patient with 3,4-methylenedioxymethamphetamine intoxication and multi-organ failure has been described. Main body While 3,4-methylenedioxymethamphetamine was very effectively removed by CytoSorb in vitro, the degree of removal in the clinical setting described may have been minimal. Indeed, the therapy was started relatively late in this case, and, as the therapy is concentration dependent, the removal of 3,4-methylenedioxymethamphetamine is likely to have been limited. On the other hand, in this case, CytoSorb hemoadsorption was very effective to treat rhabdomyolysis and hyperinflammation. Conclusion The in vitro experimentation demonstrates that 3,4-methylenedioxymethamphetamine is effectively removed by CytoSorb. However, it is debatable whether the case report confirms the possibility of in vivo removal of 3,4-methylenedioxymethamphetamine by CytoSorb. Nevertheless, the potential of the CytoSorb device to contribute to the treatment of many critically ill patients has yet to be fully explored, and further studies are warranted.

The objective of this case report is the visualization and assessment of ingested or inserted foreign bodies by postmortem computed tomography and autopsy. The presence of foreign objects in the gastrointestinal tract involves, among many other medical subdisciplines, the fields of forensic medicine and psychiatry. We present a case of an 18-year-old female Caucasian with borderline personality disorder who was found unconscious in a closed psychiatric ward with suspected ingested foreign bodies. Cardiopulmonary resuscitation was unsuccessful. Postmortem computed tomography revealed several sharp foreign bodies in the intestine varying in radiodensity and shape but not perforating any anatomic structures. The autopsy showed well-preserved tablets in the intestine, a few inserted glass fragments and one metal fragment. Ultimately, fatal intoxication involving a mixture of opioids, benzodiazepines, neuroleptics and antidepressants resulted. This case illustrates the potential contribution of postmortem computed tomography in diagnosing, localizing and defining ingested and inserted foreign bodies in deceased as well as living individuals. Thus, diagnostic imaging might increase safety not only for the affected individuals but also for medical staff.

Metformin-associated lactic acidosis is a rare side effect in metformin poisoning. There is conflicting data about mortality rates changing from 3% to 83%. We aimed to discuss a case that developed lactic acidosis and acute renal failure progressing to mortality due to metformin intoxication. A 33 year-old female patient was admitted to the emergency department, with nausea and vomiting after taking 30 tablets of 1000 mg metformin. In the 2nd hour of follow-up, patient was observed to develop lactic acidosis which did not recover despite the infusion replacement treatments and hemodialysis. Following the development of respiratory failure, under mechanical ventilation, the patient developed cardiac arrest at the 48th hour of her admission. In metformin intoxications, it should be remembered that acidosis deepens very quickly and can progress with mortality despite optimal supportive therapy. More specific recommendations and further studies are required for the management and treatment of acute metformin-associated lactic acidosis.

Background This case report, unlike the current literature related to vitamin D intoxication, aims to highlight the risk of self-medication, and how publicity boosts the acquisition of vitamins for different purposes, increasing consumption with no professional indication or supervision. This practice can pose a serious health risk to the population. Case presentation Our patient, a brazilian retired 64-year-old female, presented to the emergency service with post-prandial food vomiting of undigested content and stabbing abdominal pain with worsening during palpation. Concomitantly, onset of sporadic frontal headache, fatigue, hyporexia, weight loss of 18 kg in the same period, severe pruritus, musculoskeletal pain in the limbs and nocturia. The physical examination showed hypertension (160/80 mmHg) and itchy macules in the lower limb. Initially, the main diagnostic hypotheses were multiple myeloma, hyperparathyroidism and pancreatitis secondary to hypercalcemia, osteolytic neoplasms and other neoplasms that present with hypercalcemia. However, blood count, parathyroid hormone, chest X-ray, immunoglobulins, myelogram and bone marrow biopsy were not compatible with these diagnoses. Meanwhile, 25 OH vitamin D dosage and diluted vitamin D test confirmed the diagnosis of hypervitaminosis D. Hypercalcemic crisis was managed with vigorous hydration (50 ml/kg in 2 h), furosemide, bisphosphonates and blood pressure control with amlodipine and atenolol. Subsequently, the patient was discharged from the outpatient clinic with complete remission of symptoms, weight gain, serum calcium values of 10.76 mg/dL and ionizable calcium values of 6.52 mg/dL. Conclusion Our report summarizes the possible consequences of using a vitamin compound without supervision of a competent professional, as these substances are mistakenly considered non-toxic. To add, little information is available about the supplements’ metabolism and their biological effects. Therefore, It is difficult to diagnose intoxication. This case report shows that even the self-administration of a product designed to bring health benefits can become a risky behavior. These vitamin and mineral supplements are supposed to bring patient empowerment and reduce government spending in health-care, but indeed represent a significant public health concern due to possible overdose and drug interactions.

Amantadine intoxication occurred despite moderate renal dysfunction. This may have been affected by the use of donepezil, and we require careful attention to these combinations.

Background. There are several differences between sepsis surgical patients and burn sepsis. The effects of mediators and pathogens lasts for months if burn injury is greater than 30 % TBSA. The purpose is to improve the fluid therapy regimens for burn septicotoxemia and burn sepsis. Materials and methods. The study is based on the observation of 52 patients with burn sepsis treated at the Kyiv City Clinical Hospital No. 2 during 2017–2019. The patients were divided into three groups: first group received Ringer lactate, sodium chloride and other iso-osmolar solutions, second group – Ringer lactate + Reosorbylact at a dose of 10 ml/kg per day, third group – Ringer lactate + Reosorbylact at a dose of 15 ml/kg per day. Result. Patients received plasma to correct the wrapping system, 20 % albumin was administered when total protein level was below 50g/l. Daily use of Reosorbylact at a dose of 10–15 ml/mg helped to reduce the number of leukocytes, leukocyte intoxication index, low molecular weight metabolites (urea and creatinine), as well as the content of MSM in plasma (1.6 times), and reduce the activity of AST and ALT, lowering the level of CRР. During the observation in patients of groups 2 and 3 there was a significantly lower heart rate than in the group of crystalloids (P = 0.002), as well as higher mean blood pressure (P = 0.03), an increase in diuresis. The 24-hour fluid balance in the patients of the study groups was respectively: 64 ml/kg; 60 ml/kg and 52 ml/kg. Septic shock developed in 15.7 %, 11.8 % and 12.5 % patients of the study groups. Patients had a shorter duration of treatment with vasopressors (2.8 ± 1.5 days vs. 4.7 ± 1.4 days). Conclusions: The use of reosorbylact for patients with burn sepsis has led to a decrease in the overall fluid balance during the day. The incidence of septic shock decreased by 3.9 % and 3.2 % in the groups where Reosorbylact was used, the duration of vasopressor treatment decreased by 0.4 and 1.9 days. The detoxication and hemodynamic effect of Reosorbylact has been proved. A dose-dependent effect of Reosorbylact was observed. The study had some limitations. Thus, the conclusion of the study needs further study with more sampling

Very few reports exist on serious cardiac complications associated with intake of serotonin-noradrenaline reuptake inhibitors. This paper describes and discusses the case of a patient who ingested a dose of 17.5 g venlafaxine. She developed a full serotonergic syndrome leading to multi-organ failure, including refractory cardiovascular shock, which was managed by early implantation of an extracorporeal life support (ECLS) system as a bridging strategy. This intervention was successful and resulted in full recovery of the patient.

The purpose of the research is to evaluate therapeutic efficiency of Gamavit in the cases of dehelminthization of puppies and kittens. Materials and methods. Researches were conducted on 18 puppies and 20 kittens of different breeds at the age from 3 weeks to 3 months which had been divided based on analogues into two groups on each animal type. Precautionary dehelminthization was conducted for one part of animals, forced dehelminthization for the other part of animals (presence of helminths' ootids in fecal masses Toxocara canis, Toxascaris leonina, Uncinaria stenocephala, Ancylostoma caninum). Anthelmintic Dirofen-suspension was administered to animals of the first group orally as prescribed by instructions. Gamavit at a dose of 0.2 ml/kg was additionally administered as a single dose subdermally during dehelminthization of kittens and puppies of the second group.Results and discussion. Vomiting, decreased appetite were noted in animals of control group (without administration of Gamavit) after dehelminthization. Visible adverse changes were not noted in animals of experimental group (with administration of Gamavit). Weakening of leukocytosis and lowering of ERS, increase in red blood cells and hematocrit level, descreased activity of transferring enzymes and LDH level were noticed in animals of this group suggestive of weakening of intoxication and inflammatory reaction. In contrast, increased activity of transferring enzymes and LDH level were noticed in animals of control group which allows to infer about persisting inflammatory events. Consequently, high therapeutic efficiency of Gamavit in the cases of precautionary and forced dehelminthization were elucidated.

Aim: The purpose of this study was to investigate the protective effects of ethyl pyruvate (EP) and dimethyl sulfoxide (DMSO) on ischemic tissue in brain and cardiac and hepatic tissues in experimentally induced carbon monoxide (CO) intoxication. Material and Methods: Thirty-five mature female Sprague Dawley rats were randomized into five groups of seven animals each. Group 1 received no CO or treatment. Rats in groups 2, 3, 4 and 5 were made to inhale a high-concentration 5000 ppm CO gas mixture for 60 min at 4 L/min. CO levels were then measured from 1 mL tail vein blood. Group 2 received no therapeutic agent, group 3 received 6 mg/kg intraperitoneal (ip) DMSO, group 4 received 50 mg/kg ip EP, group 5 received 50 mg/kg EP and 6 mg/kg DMSO ip. All rats were sacrificed by decapitation. Brain, cardiac and hepatic tissues were removed and histopathological scores were compared. Results: Comparison of group 2 with group 3 and group 2 with group 5 revealed that DMSO alone and EP + DMSO exhibited a reducing effect on degree of cerebral neuronal alteration, degenerative neuron rates, and total cardiac injury score (p=0.005, p=0.002, p=0.004 and p=0.002, p=0.001, p=0.004 respectively). There was no histopathological difference between group 2 and group 4 suggesting EP alone had no therapeutic effect on histopathological injury. Conclusion: Based on our study findings, EP administered alone exhibited no protective effects on the organ injuries investigated, while DMSO exhibited reducing effects on degree of neuron alteration, rates of degenerative neurons, and total cardiac injury scores. An ameliorating effect on cardiac and hepatic injury was more prominent with combined treatment. WOS:000598268200007

BACKGROUND: The “Ospedali Riuniti’s Poison Center” (Foggia, Italy) provides a 24 h telephone consultation in clinical toxicology to the general public and health-care professionals, including drug information and assessment of the effects of commercial and industrial chemical substances, toxins but also plants and mushrooms. It participates in diagnosis and treatment of the exposure to toxins and toxicants, also throughout its ambulatory activity. METHODS: To report data on the epidemiology of mushroom poisoning in people contacting our Poison Center we made computerized queries and descriptive analyses of the medical records database of the mushroom poisoning in the poison center of Foggia from January 2018 to December 2018. RESULTS: A total of 69 mushroom poisonings cases were recorded in our poison center the period from January 2018 to December 2018. Our poison center serves all the Italian territory but most of the calls about mushrooms poisonings, in 2018, came from Apulia, Campania, and Basilicata, which are bordering regions of Italy. About 80.2 % of calls were made by the physicians (particularly, 73.9% by emergency room, 18.8% and 4.3% by hospital ward, and 1.4% both by a general practitioner and by the American Sign Language [“ASL”]) and 18.8% by the public. Cooked mushrooms were involved in all the cases (single and multiple species). The most frequent calls were made in the period between September 2018 and December 2018; in the other months, there were only sporadic cases. All were intentional exposures in adults (>18 years). CONCLUSIONS: Mushroom exposures and poisonings are an important problem in those regions of Italy where many people adventuring in mushroom’s research without any license. This fact has contributed substantially to morbidity due to mushroom poisoning. Our database is a valuable national resource for the collection and monitoring of Italian mushroom poisoning cases in 2018 but limited to the people who called our poison center, which is one of the nine poisons centers in Italy. And since in most cases, the mushroom’s species remains unknown, it is important to quickly recognize symptoms and most frequent species involved on the Italian territory, in particular in South Italy.

Background Sodium-glucose cotransporter 2 (SGLT2) inhibitors inhibit SGLT2, which is expressed in the proximal renal tubule, and thus reduce blood glucose levels by enabling the urinary excretion of excess glucose. SGLT2 inhibitors have been reported to suppress the complications of diabetes and reduce overall mortality. However, little is known about the types of symptoms that may occur in response to an overdose of an SGLT2 inhibitor. Here, we describe a case of intoxication caused by an overdose of an SGLT2 inhibitor. Case presentation An otherwise physically healthy adult woman ingested an overdose of ipragliflozin, an SGLT2 inhibitor, and a polypill of olmesartan medoxomil, and azelnidipine in a suicide attempt. Although her blood ipragliflozin concentration was very high (9516.3 ng/mL) upon hospital arrival, her initial blood glucose level was normal, and she did not exhibit symptoms such as hypoglycemia or polyuria. Moderate renal dysfunction associated with an estimated glomerular filtration rate of 42.3 mL/min/1.73 m2 was observed. Thirty-six hours after ingestion, her blood ipragliflozin concentration decreased to a level equivalent to that observed after a therapeutic dose and her renal function improved almost simultaneously. After improvement in her renal function, the osmotic diuretic effect of the drug progressed. Her blood glucose level declined slightly but was in the normal range due to glucose administration. During the clinical course, fatal hypoglycemia was not observed. Conclusions Our case showed that an overdose of an SGLT2 inhibitor caused toxic effects on renal function, but severe hypoglycemia was not observed. Additional cases of intoxication from SGLT2 inhibitors alone would be helpful to clarify the mechanism of intoxication.

Introduction:There is no regional study presenting the pediatric intoxication cases followed in pediatric intensive care units (PICUs). As they show regional features, we aimed to present the pediatric intoxication cases followed in our PICU, and indicate our self-constituted protocol about the PICU admission rules in these patients.Methods:Demographic, clinical and laboratory data of patients who admitted with intoxication and followed in PICU between October 2015 and October 2017 were noted. PICU admission indications were evaluated.Results:Twenty-four (14%) of the 171 intoxication cases formed the study group. Fourteen (58.3%) were female. Ten cases (41.7%) were under 5 years old, 6 (20.8%) were 5-12 years and 8 (37.5%) were over 12 years. In first group, all intoxications were by accident. In second, intoxications were due to accident (n=3), during drug use in treatment dose (n=2) and as a result of child abuse (n=1). In last group, it was by accident in 2, but as a result of suicide in 6 cases. Active ingredients were; central nervous system drugs (n=9), plant (atropa belladona) (n=3), decongestant drugs (n=3), multiple drugs (n=4), intoxication by inhalation (n=1) and other drugs (n=4). Fifteen patients (62.5%) had clinical indications for PICU admission. In five (20.8%) the poison control center advised PICU admission. In four patients (16.7%) we decided PICU admission because of the fatal nature of the ingested drugs.Conclusion:Our results suggest that every clinic, by taking their availabilities into account, should form its own protocols for PICU admission for pediatric intoxication cases.

Diagnosis and treatment management is difficult in cases of intoxication with multiple drugs. A 29-year-old female patient was admitted to the emergency department with multiple doses of propranolol, biperidene, risperidone and valproic acid for suicidal purposes. She had cardiovascular collapse despite fluid therapy and multiple high-dose vasopressor infusions. Intravenous lipid emulsion (ILE) treatment was administered to the patient who had hypotension that was resistant to hyperinsulinemic euglycemia and glucagon therapy. Hemodynamic stability was achieved after three hours. Intoxication with beta-blockers may be life threatening. Propranolol is a beta-blocker drug that binds highly to plasma proteins and has high lipophilic properties. The classical therapies recommended for severe beta-blocker intoxications may be insufficient, and successful results can be obtained with ILE application. In this case report, we wanted to emphasize that management of multiple drug intoxication is difficult and ILE treatment may be successful in treatment-resistant beta-blocker intoxications.

Limited information is available on the long-term follow-up and seizure recurrence in dogs with reactive seizures due to suspected exogenous toxicity. The purpose of this study was to report the long-term follow-up of 13 dogs referred to a single referral hospital, diagnosed with reactive seizures and treated with a standardized levetiracetam protocol. All dogs received a loading levetiracetam dose of 60 mg/kg/IV once, followed by a maintenance dose of 20 mg/kg every 8 h as part of an open-label clinical study. Levetiracetam was withdrawn after a 6-months seizure-free period by reducing levetiracetam to 20 mg/kg every 12 h for a 4-week seizure-free period, followed by levetiracetam 20 mg/kg every 24 h for a 4-week seizure-free period, before levetiracetam treatment was stopped. No adverse effects of the treatment were reported. No dogs experienced any seizures after discharge or after levetiracetam withdrawal. Median follow-up time from time of discharge was of 78 months (=6 years 6 months). The result of this study supports the use of levetiracetam for treatment of reactive seizures due to exogenous substance intoxication. Moreover, our results do not support the need for long-term antiepileptic treatment in cases of reactive seizures due to exogenous intoxication.

Ropivacaine is commonly used for post-operative pain management. We describe a case of neuroleptic malignant-like syndrome in a woman administered ropivacaine delivered using a drug infusion balloon. The presenting symptoms were confusion, agitation and fever. Blood analysis showed elevated C-reactive protein, leucocytosis and increased creatine phosphokinase. As intoxication was suspected, ropivacaine was suspended and the patient gradually improved. Possible leakage of ropivacaine into the intrathecal space may have resulted in central nervous system toxicity. LEARNING POINTS It is important to be aware of the secondary effects of common drugs. The differential diagnosis should always include side effects and drug interactions. Intoxication can lead to poor outcomes, so early recognition is key.

In the cases of acute rivaroxaban overdose, conservative management without prothrombin complex concentrate or other coagulation factors may be sufficient if renal function is normal and there is no bleeding.

PICO question Is soybean oil-based intravenous lipid emulsion (IVLE) therapy more effective than olive oil-based (ClinOleic IVLE therapy) for reducing time to recovery in cats with permethrin toxicosis? Clinical bottom line Category of research question Treatment The number and type of study designs reviewed Five case reports and one randomised clinical trial Strength of evidence Weak Outcomes reported Soybean oil-based and ClinOleic IVLE therapies can be used safely as adjuvant treatments to reduce time to recovery in cats with permethrin intoxication. However, the evidence collected suggests that soybean oil-based IVLE therapy is better in reducing the recovery time after permethrin toxicosis as compared to ClinOleic IVLE therapy Conclusion The overall findings showed that the average recovery time after soybean oil-based IVLE therapy across patients with permethrin intoxication was 8.5 hours and the average time to recovery after olive oil-based emulsions (ClinOleic therapy) was 39 hours. This may suggest that soybean oil-based formulations are a better option for reducing the recovery time in cats after permethrin toxicity. Dermal decontamination, supportive care, muscle relaxers, and anticonvulsant drugs are examples of recommended treatments before the administration of any intralipid therapies and must be used based on the clinical signs of each patient How to apply this evidence in practice The application of evidence into practice should take into account multiple factors, not limited to: individual clinical expertise, patient’s circumstances and owners’ values, country, location or clinic where you work, the individual case in front of you, the availability of therapies and resources. Knowledge Summaries are a resource to help reinforce or inform decision making. They do not override the responsibility or judgement of the practitioner to do what is best for the animal in their care.

Colchicine is used in the treatment of multiple diseases such as gout and auto-immune diseases. Although cases of multiorgan failure have been described in adults with doses usually higher than 0.8 mg/kg, the epidemiology data are scarce and the intoxication mechanisms are not well-known. The authors present the case of a 66-year-old male patient, with a medical history of depression, admitted to the emergency room (ER) due to intentional colchicine ingestion after taking 90 mg (approximately 1.125 mg/kg) 12 hours prior to medical evaluation. Besides some dizziness and sleepiness, he showed no other alteration in the physical examination. After the administration of activated charcoal, he was transferred to the intensive care unit (ICU). The laboratory findings showed mild hepatic dysfunction, acute kidney injury, and metabolic lactic acidosis. Despite treatment, severe clinical worsening with multiorgan failure, including respiratory failure complicated with multiple episodes of cardiac dysrhythmias and finally with persistent cardiac arrest, lead to the patient’s death after 13 hours of admission in the ER. Among drug intoxications, high doses of colchicine ingestion can lead to rapid multiorgan dysfunction, and patients with a severe overdose can experience irreversible multiorgan failure without presenting the typical initial gastrointestinal symptoms. Thus, it is necessary for the physicians to be alert to these situations and to be aware of the epidemiological data and clinical profile of this specific poisoning that should be managed in ICU. The authors perform a review of the cases of colchicine poisoning reported in adults between 2017 and 2019 and the differences in clinical management and outcomes.

The trend toward cannabis legalization in the United States over the past two decades has unsurprisingly been accompanied by an increase in the number of cannabis users and use patterns that potentially pose wider risks to the public like driving under the influence. As such, it is becoming increasingly important to develop methods to accurately quantify cannabis intoxication and its associated impairments on cognitive and motor function. Electroencephalography (EEG) offers a non-invasive method for quantitatively assessing neurophysiological biomarkers of intoxication and impairment with a high degree of temporal resolution. Twelve healthy, young recreational cannabis users completed a series of neurocognitive tasks with concurrent EEG acquisition using the ABM STAT X24 EEG headset in a within-subject counterbalanced design. The 1-h testbed consisted of resting state tasks and tests of attention and memory. Spectral densities were computed for resting state tasks, and event-related potentials (ERPs) were obtained for the attention and memory tasks. Theta band power (3–5 Hz) was decreased during cannabis intoxication compared to placebo during resting state tasks, as were average P400 and late positive potential (LPP) amplitudes during attention and memory tasks. Cannabis intoxication was also associated with elevated frontal coherence and diminished anterior–posterior coherence in the Theta frequency band. This work highlights the utility of EEG to identify and quantify neurophysiological biomarkers from recordings obtained during a short neurocognitive testbed as a method for profiling cannabis intoxication. These biomarkers may prove efficacious in distinguishing intoxicated from non-intoxicated individuals in lab and real-world settings.

A 46-year-old female with a history of generalized anxiety disorder was admitted after intentional ingestion of an unknown amount of emtricitabine/tenofovir alafenamide (Descovy®) in a suicidal attempt. Patient was emergently intubated secondary to severe agitation and inability to protect airways. Patient developed severe lactic acidosis early in the admission, secondary as to a possible mitochondrial toxicity. Failed attempts to fluid resuscitation with Lactate Ringer®, eventually warranted to start the patient on norepinephrine infusion. Metabolic acidosis remained refractory to bicarbonate bolus and infusion. Hypothermia and hypoglycemia were corrected. Despite the initial approach, the patient remained acidotic, and the nephrology was consulted for emergent continuous renal replacement therapy (CRRT). After three days of intensive care unit stay and CRRT, the patient improved and was successfully decannulated. Her metabolic profile also showed remarkable improvement and the metabolic lactic acidosis resolved. The previous formulation of tenofovir with disoproxil fumarate is associated with severe lactic acidosis due to inhibition of mammalian mitochondrial DNA polymerase. Risk factors include liver cirrhosis, chronic kidney disease, hepatitis B and C coinfection, and metformin use. The new pharmaceutical formulation of tenofovir with alafenamide (TAF) has caused a significant decrease in the incidence of lactic acidosis. However, its real incidence and the usual plasma level to induce toxicity and mitochondrial dysfunction are unknown. The aim of this report is to highlight the risk of severe lactic acidosis with the use of TAF.

Recently, high concentrations of caffeine present in energy drinks and over-the-counter (OTC) drugs have become a concern worldwide. Several deaths due to caffeine intoxication have been reported, necessitating caution. Typically, supportive care is used to treat caffeine intoxication. However, in severe cases of caffeine intoxication, hemodialysis may be used. For adults, a lethal blood caffeine concentration is at least 80 µg/mL, whereas lethal blood caffeine concentration is unknown for children. In the present case, a 15-year-old girl took a large dose of an OTC antipyretic analgesic to commit suicide, resulting in caffeine intoxication. In this case, even though blood caffeine concentration was higher than the adult lethal dose, the patient recovered through a simple treatment with intravenous infusion of extracellular fluid.

Zinc phosphide is a commonly used rodenticide in India. Intoxication is associated with multiorgan failure and high mortality. We present a case of 17-year-old adolescent female with suicidal zinc phosphide poisoning, complicated to acute pulmonary edema and refractory shock. The patient responded well to supportive management and intravenous magnesium sulfate. As there is no specific antidote for zinc phosphide, the parenteral magnesium sulfate can be used as adjunct therapy.

One of the drugs used to treat attention deficit hyperactivity syndrome is atomoxetine. Usually, the drug is well tolerated but in rare cases adverse advents may occur. An 18-year-old female under atomoxetine (60 mg/d) since 2 years for attention deficit hyperactivity syndrome since age 13 years, developed sudden onset headache, hemianopia to the right, hypoesthesia of the tongue and right arm, aphasia, and depersonalisation. Blood tests revealed hyper-CK-emia of 2860U/L, cerebral magnetic resonance imaging showed disturbed perfusion on the left temporo-parieto-occipital region, and electroencephalography (EEG) revealed focal slowing and spikes and sharp waves in the same projections. After discontinuation of atomoxetine, symptoms, EEG, and magnetic resonance imaging findings resolved spontaneously within 48 hours. In conclusion, atomoxetine may rarely cause severe side effects such as complex partial seizures with CK-elevation, transient hypoperfusion of the temporal, parietal and occipital lobes, and prolonged reorientation. Atomoxetine should be discontinued if such side effects occur.

In morphine intoxication cases, forensic toxicologists are frequently confronted with the question of if the individual was opioid-tolerant or opioid-naïve, which can be investigated by hair analysis. However, interpretation of results can be challenging. Here, we report on hair testing for morphine and its metabolite hydromorphone following morphine intoxication without tolerance and upon chronic use. Two consecutive hair samples were collected after a non-fatal intoxication. Analysis comprised short hair segments and their initial wash water solutions. In the intoxications, morphine and hydromorphone levels were 3.3 to 56 pg/mg and at maximum 9.8 pg/mg, respectively. Both levels and hydromorphone to morphine ratios were significantly lower compared to chronic morphine use. In the non-fatal intoxication, the highest hydromorphone to morphine ratio was obtained in the segment corresponding to the time of intoxication. Morphine ratios of wash to hair were significantly higher in the intoxications compared to chronic use, being indicative of sweat/sebum contamination. We recommend including the analysis of hydromorphone and the initial wash solution in cases of morphine intoxications. Our study demonstrates that hydromorphone to morphine ratios can help in distinguishing single from chronic morphine use and in estimating the period of exposure when a consecutive hair sample can be collected in survived intoxications.

International audience; Extracorporeal membrane oxygenation (ECMO) is frequently used in many centers around the globe for various indications. However, prognosis is often poor even with all supportive therapies, and in many cases, clinical deterioration is associated with inflammation. Hemoadsorption with CytoSorb is a novel approach to limit the inflammatory response, and the device can be safely and easily installed into ECMO circuits. CytoSorb has been used more than 130.000 times to date, but because randomized controlled trials are largely lacking, there is substantial debate on its use. Here, experts from critical care medicine, cardiology, cardiac surgery, and perfusion technology discuss the pros and cons of this novel therapy and outline the future aspects for its clinical application and research.

Rationale and objectivesRecent studies reported that when given a mutually exclusive choice between cocaine and palatable food, most rats prefer the non-drug reward over cocaine. However, these studies used rat strains with limited genetic and behavioral diversity. Here, we used a unique outbred strain of rats (Heterogeneous Stock, HS) that mimic the genetic variability of humans.MethodsWe first identified individual differences in addiction-like behaviors (low and high). Next, we tested choice between cocaine and palatable food using a discrete choice procedure. We characterized the individual differences using an Addiction score that incorporates key features of addiction: escalated intake, highly motivated responding (progressive ratio), and responding despite adverse consequences (footshock punishment). We assessed food vs. cocaine choice at different drug-free days (without pre-trial cocaine self administration) during acquisition of cocaine self-administration or after escalation of cocaine self-administration. We also assessed drug vs. food choice immediately after 1-, 2-, or 6-h cocaine self-administration.ResultsIndependent of the addiction score, without pre-trial coccaine (1 or more abstinence days) HS rats strongly preferred the palatable food over cocaine, even if the food reward was delayed or its size was reduced. However, rats with high but not low addiction score modestly increased cocaine choice immediately after 1-, 2- or 6-h cocaine self-administration.ConclusionsLike other strains, HS rats strongly prefer palatable food over cocaine. Individual differences in addiction score were associated with increased drug choice in the presence but not absence (abstinence) of cocaine. The HS strain may be useful in studies on mechanisms of addiction vulnerability.