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Artificial intelligences (AIs) are emerging in the field of medical informatics in many areas. They are mostly used for diagnosis support in medical imaging but have potential uses in many other fields of medicine where large datasets are available.To develop an artificial intelligence (AI) "ToxNet", a machine-learning based computer-aided diagnosis (CADx) system, which aims to predict poisons based on patient's symptoms and metadata from our Poison Control Center (PCC) data. To prove its accuracy and compare it against medical doctors (MDs).The CADx system was developed and trained using data from 781,278 calls recorded in our PCC database from 2001 to 2019. All cases were mono-intoxications. Patient symptoms and meta-information (e.g., age group, sex, etiology, toxin point of entry, weekday, etc.) were provided. In the pilot phase, the AI was trained on 10 substances, the AI's prediction was compared to naïve matching, literature matching, a multi-layer perceptron (MLP), and the graph attention network (GAT). The trained AI's accuracy was then compared to 10 medical doctors in an individual and in an identical dataset. The dataset was then expanded to 28 substances and the predictions and comparisons repeated.In the pilot, the prediction performance in a set of 8995 patients with 10 substances was 0.66 ± 0.01 (F1 micro score). Our CADx system was significantly superior to naïve matching, literature matching, MLP, and GAT (Our AI trained on a large PCC database works well for poison prediction in these experiments. With further research, it might become a valuable aid for physicians in predicting unknown substances and might be the first step into AI use in PCCs.

ZUSAMMENFASSUNGDas Wissen um Charakteristika suizidal intendierter Selbstvergiftungen sowie Faktoren, die mit einem wiederholten Suizidversuch assoziiert sind, ist für die Identifikation von potenziellen Risikopatienten und -konstellationen wertvoll. Daher wurden in einer prospektiven Beobachtungsstudie in einem Zeitraum von 12 Monaten Daten von 1238 Patienten mit suizidalen Intoxikationen, zu denen unser Giftnotruf kontaktiert wurde, gesammelt und ausgewertet. Die erhobenen Informationen umfassen neben demografischen Daten auch Angaben zu Symptomen, eingenommenen Substanzen bzw. deren Quelle, somatisch-psychiatrischen Komorbiditäten, früheren Suizidversuchen, Vorliegen einer Substanzkonsumstörung sowie einer Koingestion von Alkohol oder illegalen Drogen.53 % der Patienten waren zwischen 18 und 44 Jahre alt, 66 % waren weiblich. 79 % der Patienten litten an einer psychiatrischen Erkrankung, 45 % hatten mindestens einen Suizidversuch hinter sich. Patienten mit einer psychiatrischen Störung nahmen am häufigsten Antidepressiva und Neuroleptika ein, während Patienten ohne psychiatrische Vorerkrankung vorwiegend periphere Analgetika, insbesondere Ibuprofen, verwendeten. Im Vergleich zu Patienten mit einem Erstereignis wiesen diejenigen mit einem wiederholten Suizidversuch häufiger eine psychiatrische Erkrankung oder eine Substanzkonsumstörung auf und ingestierten bevorzugt Antidepressiva und Neuroleptika, jedoch seltener periphere Analgetika. Neben der Identifikation von Charakteristika vorsätzlicher Selbstvergiftungen konnten mit dem Vorliegen einer psychiatrischen Erkrankung, eines gestörten Substanzgebrauchs sowie der Ingestion von Antidepressiva oder Neuroleptika Risikofaktoren für einen wiederholten Suizidversuch detektiert werden, auf deren Basis individuelle Präventivmaßnahmen für Risikogruppen entwickelt werden können.

To independently validate the predictive value of the Tanta University Risk Model for intensive care requirement in unselected poisoned patients. Retrospective chart review of 293 poisoned patients. The Tanta University Risk Model was calculated as follows: Tanta University Risk Model = −1.966*Glasgow Coma Scale − 0.329*oxygen saturation − 0.212*diastolic blood pressure + 0.27*respiratory rate − 0.33*standard bicarbonate. It was then compared to a composite endpoint indicating an intensive care unit requirement (death in hospital, vasopressors, need for intubation). Nineteen of 293 patients had a complicated clinical course as defined by meeting the primary endpoint definition. Receiver operating characteristic analysis revealed the area under the curve to be 0.79 (95% confidence interval 0.73–0.83). A positive Tanta University Risk Model was defined >−73.46. Fifteen out of 84 patients with a positive Tanta University Risk Model had a complicated course, while four of 209 patients with a negative Tanta University risk model had a complicated course (P

Patients who use recreational drugs frequently co-ingest ethanol, which is considered a central nervous system (CNS) depressant. The clinical relevance of this in acute toxicity involving other CNS depressants is not well described.To assess the clinical impact of ethanol co-use in patients presenting to the emergency department (ED) with acute toxicity involving the use of CNS depressant drugs.A retrospective multicentre study using data from the Euro-DEN Plus database from January 2014 to December 2019.Comparison of epidemiologic and clinical characteristics, ED and hospital management of patients with CNS depressant intoxication with or without ethanol co-use.Although 7644 (17.5%) of the 43 633 presentations were included, ethanol was co-ingested in 3811 (49.9%). In total 53.3% required medical treatment, 14 patients died. Patients with ethanol co-use more frequently presented with a Glasgow Coma Scale (GCS) ≤8 (34.1% vs. 22.4%; P 0.001), vomiting (8.1% vs. 4.6%; P 0.001), anxiety (12 % vs. 6.4%; P 0.001), agitation/aggression (22% vs. 14.7%; P 0.001), seizures (3.8% vs. 2.4%; P 0.001) and hypotension (7.5% vs. 4.6%; P 0.001). They more often required ambulance transport (85.5% vs. 76.5%; P 0.001), medical treatment (57.3% vs. 48.0%; P 0.001), hospitalization (27.7% vs. 18.9%; P 0.001), and admission to intensive care (12.2% vs. 4.0%; P 0.001). Subgroup analysis showed that GCS ≤8 was particularly common in patients who combined ethanol with opioids or gamma-hydroxybutyrate (GHB)/gamma-butyrolactone (GBL).Co-use of ethanol with CNS-depressant drugs appears to increase the risk of adverse effects and is associated with a higher need for medical treatment, especially when ethanol is combined with opioids or GHB/GBL.

Background Although the total number of suicides decreased since the beginning of the 1980s, the number of suicide-related behaviors using self-intoxication increased. Therefore, research on the characteristics of individuals committing self-intoxication becomes of growing importance for risk assessments and the development of preventive measures. Methods In this prospective, observational, monocentric cohort study, all incoming calls at our Poisons Control Centre reporting suicide-related behaviors through self-intoxication, were analyzed via a standardized questionnaire over 12 months. Both univariate and bivariate analyses were performed. Results 1238 cases of deliberate intoxication were included in the study. The majority of cases occurred in the age group between 18 and 44 (n = 607/49%), two-thirds were female (n = 817/66%). The main substances used were antidepressants (n = 420/34%), peripheral analgesics (n = 322/26%) and neuroleptics (n = 282/23%). The majority of patients ingested substances from their prescribed medication (n = 640/82%) with the highest proportion in those aged over 64 years (n = 72/113; 91%, p Conclusion This study might contribute to identifying individuals with an increased risk of suicide-related behaviors by deliberate intoxication and to developing preventive strategies for future suicide attempt(s).

Seizures are a recognized and potentially serious complication of recreational drug use. This study examined a large international data set of presentations to Emergency Departments with acute recreational drug toxicity, the European Drug Emergencies Plus (Euro-DEN Plus) Network, to compare presentations with and without seizures and estimate incidence and associated drugs. Amongst 23,947 presentations between January 2014 and December 2017, there were 1013 (4.2%) with reported seizures. Clinical and demographic features were similar between individuals who had a seizure and those who did not, although rates of coma, cardiac arrest, intubation, intensive care admission, and death were significantly higher in those with seizures. There was a significant association between specific drugs and a higher seizure incidence, including fentanyl (odds ratio 2.63, 95% confidence interval 1.20-5.80), and synthetic cannabinoids (OR 2.90, 95% CI 2.19-3.84). Other drugs were associated with a lower seizure incidence, including heroin (OR 0.46, 95% CI 0.35-0.61), clonazepam (OR 0.22, 95% CI 0.06-0.91), and cannabis (OR 0.65, 95% CI 0.50-0.86). This substantiates observations that the synthetic cannabinoids as a group of novel psychoactive substances are clinically different in consequence of intoxication than cannabis, and that individuals who suffer a seizure in the context of recreational drug intoxication are likely to have worse outcomes overall. Utilising this information of what substances have a greater risk of seizures, could provide tailored harm reduction and education strategies to users to reduce the risk of seizures and their associated complications.

Zusammenfassung Hintergrund Vergiftungen verursachen bei Kindern den Großteil der Notfalleinsätze in Deutschland, die durch präventive Maßnahmen verhindert oder gemildert werden könnten. Daher ist für den Pädiater das Wissen um häufige Intoxikationen essentiell. Die vorliegende Arbeit zeigt allgemeine und epidemiologische Daten zu Vergiftungen sowie einen Überblick über die häufigsten einzelnen Noxen und -kategorien im Kindes- und Jugendalter. Methoden Retrospektiv wurden Vergiftungsfälle bei Kindern und Jugendlichen aus 6 deutschen Giftnotrufzentralen (2012–2016 und 2002–2016) ausgewertet. Kategorielle Daten sind als Mittelwerte±Standardabweichung, häufigste Noxen nach Punkten angegeben. Ergebnisse Die Anruferzahl insbesondere der Laien nahm ab 2002 deutlich zu. Zwei Drittel der Fälle traten bei Klein- und Vorschulkindern auf, häufiger bei Jungen (50%) als bei Mädchen (44%), bei Jugendlichen überwiegen weibliche Patienten (>60%). Im Alter95%), bei Jugendlichen treten suizidale Intoxikationen und Abusus (13%) in den Vordergrund. 90% der Fälle verlaufen asymptomatisch oder leicht, wobei der Anteil der klinisch symptomatischen Fälle mit dem Alter zunimmt (Jugendliche 13% vs. Säuglinge 1%). Vergiftungen mit Medikamenten stellen bei Jugendlichen die häufigste Gruppe dar, bei Kindern tensidhaltige Reinigungsmittel und Kosmetika, Sanitärreinigungsmittel, Tabak, Knicklicht und Entkalker in Lösung. Diskussion und Schlussfolgerung Stetig steigende Anruferzahlen von Fachpersonal und Laien veranschaulichen die Bedeutung der Giftnotrufzentralen. Obwohl Vergiftungen bei Kindern und Jugendlichen meist asymptomatisch oder mit leichten Symptomen verlaufen, darf die Relevanz präventiver Maßnahmen v. a. bei Kindern

To define the demographics of German-speaking "bath salt" users.Prospective web-based survey of volunteer users of "bath salts". Subject recruitment/exclusion: Participation was solicited by posts in web forums frequented by users of synthetic cathinones. An invitation to participate was also disseminated via regional drug information centers. Responses were discarded if participants refused data analysis, provided incomplete surveys, were under 18 years of age (five cases), and in case of clearly improbable answers (i.e., two cases with profanity typed in free-form input fields). Overall 96 out of 180 participants provided complete questionnaires. These were further analyzed.74% of respondents were male. 41% were under the age of 30 and a further 38% between 30 and 39 years old. Cathinones were used on more than 10 days in the preceding year by 62% of study subjects. The nasal and intravenous routes of administration were most often used. About 80% of respondents reported binge use. There were frequent co-administrations of opioids and opiates. The most common complication was prolonged confusion (47%). 16% had been involuntarily confined. One third had thoughts of violence and 16% acted on these thoughts either against themselves or others. About 44% reported high-risk sexual activity under the influence of cathinones. About 31% had driven or ridden a bike while intoxicated. About 6% had problems with law-enforcement for selling cathinones and 16% for crimes committed under the influence of cathinones. In conclusion, cathinone users are typically young males in their twenties and thirties. Most are experienced drug users, particularly of alcohol and opiates/opioids. The impact on society is tremendous as evidenced by high rates of self-reported violence, high-risk sexual activity, crimes, and traffic violations.

Background Treatment of multiple organ failure frequently requires enhanced hemodynamic monitoring. When renal replacement is indicated, it remains unclear whether transpulmonary thermodilution (TPTD) measurements are influenced by renal replacement therapy (RRT) and whether RRT should be paused for TPTD measurements. Our aim was therefore to investigate the effect of pausing RRT on TPTD results in two dialysis catheter locations. Materials and methods In total, 62 TPTD measurements in 24 patients (APACHE: 32 ± 7 [mean ± standard deviation (SD)]) were performed using the PiCCO™ system (Pulsion, Germany). Patients were treated with sustained low efficiency dialysis (SLED; Genius™ system, Fresenius, Germany) as RRT. Measurements were taken during ongoing hemodialysis (HD, HDO), during paused HD (HDP) and immediately after termination of HD and blood restitution (HDT). Dialysis catheters were placed either in the superior vena cava (SVC, 19 times) or in the inferior vena cava (IVC, 5 times). Statistical analysis was performed to assess the effects of the measurement setting, SLED (blood flow rate) and the catheter location, on cardiac index (CI), global end-diastolic volume index (GEDVI) and extravascular lung water index (EVLWI) as measured by TPTD. Multilevel models were used for the analysis due to the triplicate measurements and due to 12 out of 19 SVC and 2 out of 5 IVC patients having more than one TPTD measured. Results CI and GEDVI were significantly higher at time point HDP compared to both HDO and HDT. In contrast, values for EVLWI were lower at HDP when compared to HDO and HDT. These findings were independent of the site of dialysis catheter insertion and blood flow rate. Conclusions PiCCO™ measurements assessed at paused SLED significantly deviate from ongoing and terminated SLED. Therefore, the dialysis system should not be paused for measurements. TPTD measurements in patients with PiCCO monitoring seem sufficiently reliable during ongoing SLED as well as after its termination. An effect of dialysis catheter location (SVC vs IVC) and blood flow rate on PiCCO™ measurements could not be shown.

In Germany, intoxications cause the bulk of emergencies in children, to be prevented or attenuated by preventive measures. Therefore, knowledge about intoxications is essential for pediatricians. The present work provides general and epidemiologic data about intoxications and most frequent categories and single toxicants.Data of intoxications in children and adolescents from 6 German poison centers (2012-2016 and 2002-2016) were retrospectively analyzed. Categorical data are given as mean±standard deviation, most frequent toxicants as a score.Calls, especially from non-professionals, increased since 2002. Two third of intoxications occurred in small and pre-school children, more frequently in boys (50%) than girls (44%), in adolescents girls predominated (60%).14 years intoxications occur mainly at home, day care or school (95%), in adolescents suicide attempts and abuse come to the fore (13%). 90% of the cases are asymptomatic or mild, with increasing symptoms at higher ages (adolescents 13% vs. small children 1%). Intoxications with drugs are predominantly in adolescents, surfactant containing cleaning agents and cosmetics, sanitary cleaner, tobacco, glow lights and solute descaler in children.Increasing incoming calls from professionals and non-professionals point out the importance of the poison centers. Although intoxications in children and adolescents mainly proceed without or mild symptoms, the relevance of preventive measures especially for children7 should not be underestimated.Vergiftungen verursachen bei Kindern den Großteil der Notfalleinsätze in Deutschland, die durch präventive Maßnahmen verhindert oder gemildert werden könnten. Daher ist für den Pädiater das Wissen um häufige Intoxikationen essentiell. Die vorliegende Arbeit zeigt allgemeine und epidemiologische Daten zu Vergiftungen sowie einen Überblick über die häufigsten einzelnen Noxen und -kategorien im Kindes- und Jugendalter.Retrospektiv wurden Vergiftungsfälle bei Kindern und Jugendlichen aus 6 deutschen Giftnotrufzentralen (2012–2016 und 2002–2016) ausgewertet. Kategorielle Daten sind als Mittelwerte±Standardabweichung, häufigste Noxen nach Punkten angegeben.Die Anruferzahl insbesondere der Laien nahm ab 2002 deutlich zu. Zwei Drittel der Fälle traten bei Klein- und Vorschulkindern auf, häufiger bei Jungen (50%) als bei Mädchen (44%), bei Jugendlichen überwiegen weibliche Patienten (60%). Im Alter14 Jahre sind Intoxikationen auf Unfälle in Haushalt, Kindertagespflege oder Schulen zurückzuführen (95%), bei Jugendlichen treten suizidale Intoxikationen und Abusus (13%) in den Vordergrund. 90% der Fälle verlaufen asymptomatisch oder leicht, wobei der Anteil der klinisch symptomatischen Fälle mit dem Alter zunimmt (Jugendliche 13% vs. Säuglinge 1%). Vergiftungen mit Medikamenten stellen bei Jugendlichen die häufigste Gruppe dar, bei Kindern tensidhaltige Reinigungsmittel und Kosmetika, Sanitärreinigungsmittel, Tabak, Knicklicht und Entkalker in Lösung.Stetig steigende Anruferzahlen von Fachpersonal und Laien veranschaulichen die Bedeutung der Giftnotrufzentralen. Obwohl Vergiftungen bei Kindern und Jugendlichen meist asymptomatisch oder mit leichten Symptomen verlaufen, darf die Relevanz präventiver Maßnahmen v. a. bei Kindern7 Jahren nicht unterschätzt werden.

Background Acanthamoeba species can cause disseminating infections in immunocompromised individuals. Case presentation Here, we report a case of granulomatous acanthamoebic encephalitis with a lethal outcome in a 54-year-old German man who was human immunodeficiency virus-positive. The diagnosis was based on symptoms of progressive neurological deficits, including sensorimotor paralysis of his right leg and deteriorating alertness. Due to the rapid course and rather late diagnosis of the infection, effective treatment could not be applied and he died 12 days after hospital admission. Conclusions To the best of our knowledge, this is the second case of granulomatous acanthamoebic encephalitis reported within Germany. Our case highlights the importance of early diagnosis of granulomatous acanthamoebic encephalitis to prevent fatal outcome.

To define the characteristics of synthetic cathinone users admitted to hospital including clinical and laboratory parameters and the complications of use.Retrospective single-center study of patients treated for acute cathinone intoxication and complications of cathinone use between January 2010 and January 2016.A specialized clinical toxicology unit at an academic tertiary care center in Southern Germany serving a population of about 4 million.81 consecutive patients with laboratory-confirmed use of cathinones who presented for acute intoxication or complications of cathinone use were retrospectively analyzed.The patients were predominantly male (64%, 52/81) with a median age of 34 years. 60 were admitted for signs of acute intoxication while 21 suffered from complications of cathinone use. 70% of acutely intoxicated patients had an increased creatinine phosphokinase. Only a minority of patients presented with a sympathomimetic toxidrome. Three patients had infectious complications, 10 prolonged psychosis, 6 rhabdomyolyses and/or kidney failure, and two patients died. Based on presentations, cathinone use has increased with the first cases seen in 2010. Opiates/opioids are the main co-ingested drugs of abuse. The pattern of cathinone use shifted from methylone in 2010/2011 to 3,4-methylenedioxypyrovalerone (MDPV) and 3-methylmethcathinone (3-MMC) in 2014/2015. We conclude that in our setting "typical" cathinone users are males in their thirties. They are seldom drug naïve and regularly co-ingest illicit drugs. Preventive measures have to be tailored to these difficult to reach patients. Present efforts to educate young clubbers in their late teens may fail to reach the pertinent demographic.

To independently validate the predictive value of the intensive care requirement score (IRS) in unselected poisoned patients.Retrospective chart review.Five hundred and seventeen out of 585 admissions for acute intoxications could be analyzed. Eleven were excluded for a condition already requiring intensive care unit (ICU) support at admission (e.g., preclinical intubation). A further 57 admissions were excluded due to missing data. The IRS was calculated using a point-scoring system including age, Glasgow Coma Scale, heart rate, type of intoxication, and preexisting conditions. It was then compared to a composite endpoint indicating an ICU requirement (death in hospital, vasopressors, need for ventilation). The endpoint and the point-scoring system were identical to the original publication of the score.Twenty-three out of 517 patients had a complicated clinical course as defined by meeting the endpoint definition. Twenty-one out of 23 complicated courses had a positive IRS (defined as greater or equal 6 points), as compared to 255/494 patients with an uncomplicated clinical course (p .001, Fisher's exact test). One patient (with a positive IRS) died. The negative predictive value of the IRS was 0.99 (95% CI: 0.97-1), the sensitivity was 0.91 and the specificity 0.48. In conclusion, the IRS is significantly linked to outcome. While a negative IRS virtually excludes the need for ICU care, a positive IRS has a positive predictive value too low to be used for risk stratification. The IRS could also be applied to unselected admissions of poisoned patients.

In acute myocardial infarction (AMI), monocyte procoagulant activity is increased and may contribute to the risk for recurrence and other thrombotic events. This study sought to investigate the role tissue factor (TF) and tissue factor pathway inhibitor-1 (TFPI-1) in the regulation of monocyte procoagulant activity in AMI. Serial venous blood samples were obtained from 40 patients with AMI undergoing revascularization by stent placement. Twenty patients with elective stenting for stable angina served as control subjects. TF proteolytic activity was measured with spectrozyme factor Xa (FXa), TF and TFPI-1 surface expression on monocytes by flow cytometry, RNA expression in whole blood by reverse transcription-polymerase chain reaction, and concentrations of plasma prothrombin fragments F(1 + 2) by immunoassay. Forty-eight hours after AMI, an increase was found in TF RNA, followed by an increase in TF surface expression by 24% +/- 4% and in plasma concentration of F(1 + 2) by 103% +/- 17% (P