Hospital referrals of patients with acute poisoning by the Belgian Poison Centre: analysis of characteristics, associated factors, compliance and costs.

OBJECTIVE: Aims were (1) to assess the characteristics, associated factors and compliance of patients with acute poisoning advised by the Belgian Poison Centre (BPC) to go (conditionally) to the hospital, (2) to assess the compliance and potential health-economic impact. METHODS: Three types of referrals to the hospital of patients who called the BPC between 1 January and 30 June 2018 were analysed: referrals in case of deterioration in the patient's condition (Hosp-watchful-wait), referrals (Hosp-referral) or urgent referrals (Hosp-urgent-referral). Factors associated with type of recommendation were registered. A survey was conducted on a second dataset of patients who called the BPC between 1 March and 15 May 2019 and referred (conditionally) to the hospital. RESULTS: 5476 referrals were included: 72.4% accidental poisoning, 25.3% intentional self-harm, 1.2% substance abuse and 1.1% unclear intentionality. There were 2368 (43.2%) Hosp-watchful-wait cases, 2677 (48.9%) Hosp-referrals and 431 (7.9%) Hosp-urgent-referrals. In Hosp-watchful-wait cases, soaps and detergents were represented most (20.5%). In Hosp-referrals and Hosp-urgent-referrals, benzodiazepines (12.7% and 15.1%, respectively) predominated. Factors associated with hospitalisation type were number of symptoms, intentionality, type of agent(s) involved and advising antidotes. The survey showed that 7.8% of Hosp-watchful-wait patients went to the hospital versus 57.3% of Hosp-referrals and 59.6% of Hosp-urgent-referrals. The mean cost for Hosp-watchful-wait patients, Hosp-referrals and Hosp-urgent-referrals was estimated at €127, €767 and €796, respectively. CONCLUSION: Only a small proportion of patients followed the advice of the BPC to go (conditionally) to the hospital. A systematic follow-up of cases is warranted to examine the appropriateness of referrals and the compliance of patients.

[Advances in the application of clinical toxicology in the treatment of acute poisoning].

Acute poisoning is a component of emergency medicine and a key public health problem in clinical toxicology. In recent years, the research and development of industrial chemicals and drugs have developed rapidly, and the incidence of acute drug poisoning has been increasing. It is very important to strengthen the application research of clinical toxicology in acute poisoning, to identify rare and new toxic drugs, and to create conditions for rapid detection of toxic substances. Therefore, this article reviews the types of acute poisoning, the epidemiological characteristics, the detection technology and significance of clinical toxicology, the role of clinical toxicology in the treatment of acute poisoning and its application.

Using textual cause-of-death data to study drug poisoning deaths.

Death certificate data are often used to study the epidemiology of poisoning deaths, but the International Classification of Diseases (ICD) codes used to tabulate death data do not convey all of the available information about the drugs and other substances named on death certificates. In the United States and some other countries, the SuperMICAR computer system is used to assign ICD codes to deaths. The SuperMICAR system also stores a verbatim record of the text entered for the cause of death. We used the SuperMICAR text entries to study the 7,817 poisoning deaths that occurred among Washington State residents between 2003 and 2010. We tabulated the drugs named on death certificates and computed age-adjusted and age-specific death rates for the top-named drugs and for prescription and illicit drugs. Methadone was named on 2,149 death certificates and was the most frequently named substance, followed by alcohol, opiate, cocaine, oxycodone, and methamphetamine. For both men and women and at all ages, prescription drugs were involved in more deaths than were illicit drugs. Among the 25 drugs named most frequently, only 4 have unique ICD codes; the other 21 can be identified only by using the SuperMICAR data.

[Cases of poisoning in Germany. Disease entity, documentation, and aspects of the event]. / Vergiftungen in Deutschland. Krankheitsbegriff, Dokumentation und Einblicke in das Geschehen.

Cases of poisoning account for a distinct share of accidents in Germany, which is particularly high for accidents involving children. Cases of poisoning resulting from suicidal intent or abuse are not counted as accidents. Compared to other cases of disease and accidents, the numerical documentation of cases of poisoning is inadequate. Presently, there is no institution in Germany that could make available representative and meaningful data on the current state of poisoning. Owing to intensive scientific cooperation between the poison information centers (funded by the federal states) and the Poison and Product Documentation Center at the Federal Institute for Risk Assessment (BfR DocCenter) as well as to international cooperation, harmonized and standardized tools have been developed for the appropriate documentation and reporting of procedures to account for poisoning accidents. The first evaluation for 2005-2012 based on published and processed figures for the Federal Republic of Germany yielded the following results: Of approximately 230,000 telephone inquiries received in 2012, about 207,000 involved exposure of humans to different noxae. An annual increase of 3-5 % was recorded. For 2011, analyses of subsets processed by means of standardized methods yielded the following results: Medicines were involved in about 39 % of the cases recorded (of these, medicinal products for humans in 99 %); chemical/physicochemical agents in about 26 % (of these, cleaning and maintenance products in 46 %); products of daily use in about 14 % (of these, cosmetics in 40 %); and plants in about 10 %. More than 90 % of cases were acute poisoning and less than 5 %, chronic poisoning. Regarding the degree of severity of poisoning, an asymptomatic course was reported for 44 % of the cases; minor manifestations were experienced in 30 %, moderate ones in 6 %, and severe manifestations in 2 % of the cases recorded. Fatal cases were rare (< 0.1 %). The majority of cases (67 %) were caused by poisoning accidents, followed by suicidal action (20 %), with abuse and industrial poisoning (4 %) in third position; 1 % of the cases of poisoning were attributed to adverse drug reactions (ADR) and mistaking a medicinal product for another one. Infants aged 1-2 years have the highest risk of poisoning. A panel of the BfR Committee for the Assessment of Poisonings has already developed proposals for a national monitoring scheme of poisoning incidents. The aim is to prepare annual reports similar to the report of the National Poison Data System (NPDS) maintained by the American Association of Poison Control Centers (AAPCC) in the USA.

The epidemiology of acute poisonings in women of reproductive age and during pregnancy, California, 2000-2004.

The aims of this study were to describe and compare the epidemiology of acute poisoning hospital discharges in women of reproductive age and during pregnancy (aged between 15 and 44) to include the incidence rate, risk factors, substances involved, rates of intentional versus unintentional poisonings, and in pregnant women, distribution over trimesters. Through a cohort study design, the California patient discharge dataset and linked vital statistics-patient discharge database were used to identify cases of acute poisoning hospital discharges from 2000 to 2004 among women of reproductive age and among pregnant women. Odds ratios (OR) were calculated to identify risk factors using logistic regression. Of 4,436,019 hospital discharges in women of reproductive age, 1% were for an acute poisoning (115.3/100,000 person-years). There were 2,285,540 deliveries and 833 hospital discharges for an acute poisoning during pregnancy (48.6/100,000 person-years). Pregnancy was associated with a lower risk of acute poisoning (OR = 0.89, P = 0.0007). Poisonings were greatest among young black women regardless of pregnancy status and among those with substance abuse or mental health problems. Analgesic and psychiatric medications were most commonly implicated. The majority of poisonings among women of reproductive age (69.6%) and among pregnant women (61.6%) were self-inflicted. Efforts to reduce acute poisonings among women of reproductive age should include education regarding the use of over-the-counter medications and interventions to reduce self-inflicted harm.

Status and trends in poisonings in Denmark 2007-2009.

INTRODUCTION: The Danish Poison Information Centre (DPIC) provides information to the public and health care professionals on acute poisonings. The DPIC received 41,000 enquiries during the first three years of its existence as an open 24h telephone service. The aim of this data register study was to classify all substance exposures, to gain knowledge of the status and trends in poisonings (toxico-surveillance) and to evaluate the development in the number of contacts. MATERIAL AND METHODS: Information and inquiries were continuously entered into a poison-centre database. A new classification system was established during the study to ensure that all agents were properly classified. A total of 41,139 calls were divided into 18 substance categories, each consisting of 3-11 subgroups. RESULTS: The number of contacts per year increased by 70% from 2007 to 2009. Three contacts per thousand individuals in the Danish population were registered in 2009. For all groups, except drugs of abuse, the data showed an increase in the actual number of exposures from 2008 to 2009. Pharmaceuticals represent one third of substance exposures, and analgesics constitute a third of these poisonings. A relative increase in contacts concerning household substances, plants and vitamins was observed. CONCLUSION: The classification gave detailed knowledge of the current poisoning status. Evaluation of subgroups showed a need for a larger number of subgroups to ensure a sufficient level of toxico-surveillance. Compared to other national poison centres, we predict a doubling in enquiries during the next ten years, mainly from the public.

Relationship between acute kidney injury and mortality in poisoning - a systematic review and metanalysis.

RATIONALE: Three consensus classifications of acute kidney injury have been published. These are RIFLE (Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease published by the Acute Dialysis Quality Initiative workgroup), AKIN (published by the Acute Kidney Injury Network) and KDIGO (published by the Kidney Disease Improving Global Outcome workgroup). Acute kidney injury has been reported consistently as associated with worsened outcomes. However, toxicant-related acute kidney injury has been excluded from the studies used to validate the classifications of acute kidney injury. OBJECTIVE: To study whether poisoned patients who develop acute kidney injury, as defined by consensus definitions/classifications, have higher mortality compared to those who did not. METHODS: Databases were searched from 2004 to 2019 using the following keywords (KDIGO OR "Kidney Disease: Improving Global Outcomes" OR "Kidney Disease Improving Global Outcomes" OR AKIN OR "AKI network" OR "Acute kidney Injury Network" OR ADQI OR RIFLE OR "Acute dialysis quality initiative") AND (intoxication OR poisoning OR overdose OR ingestion) AND (AKI OR kidney OR renal OR ARF). If data were available, we used a random-effects meta-analysis model and Fisher's exact test to compare mortality in patients according to kidney function definitions (acute kidney injury vs not) and stages (stages vs no acute kidney injury), respectively. If data were available, we assessed the correlation between mortality and renal function (no acute kidney injury, risk/stage 1, injury/stage 2 and failure/stage 3) using the Spearman correlation. If available, we collected the results of statistical analyses in studies that have used acute kidney injury to predict mortality. RESULTS: Study selection. Thirty-three relevant studies were found, 22/33 retrospective studies (67%) and 11/33 prospective studies (33%). Paraquat was the most frequent toxicant involved (13/33, 39%). We found a disparity between studies regarding the timeframe during which mortality was assessed, the temporality of the renal function considered to predict mortality (initial/worst) and the criteria used to define/grade acute kidney injury across studies. Univariate association between acute kidney injury definitions/stages and mortality. Consensus definitions/staging of acute kidney injury were associated with higher mortality, using univariate analyses, in twenty-eight (RIFLE = 7; AKIN = 12; KDIGO = 9) studies included but not in five (AKIN = 4, KDIGO = 1). When available data were pooled, RIFLE (5 studies), AKIN (16 studies) and KDIGO definitions (8 studies) of acute kidney injury were associated with a higher mortality (Log unadjusted Odds ratios [95%-confidence interval], 2.60 [2.23; 2.97], 2.02 [1.48; 2,52] and 3.22 [2,65; 3.78], respectively). However, we found high heterogeneity (I2=54,7%) and publication bias among studies using AKIN. In ten studies with available data, the correlation between renal function (no acute kidney injury, risk/stage 1, injury/stage 2, failure/stage 3) and mortality was significant in 5 studies (RIFLE = 2; AKIN = 3), but not in five studies (RIFLE = 1; AKIN = 3; KDIGO = 1).Multivariate association between acute kidney injury definitions/stages and mortality. The definitions of acute kidney injury were associated with higher mortality in two studies (RIFLE = 2), but not in four studies (AKIN = 1 and KDIGO = 3. The stages of acute kidney injury (including one or more stages) were associated with higher mortality in four (RIFLE = 1, AKIN = 1 and KDIGO = 2). CONCLUSIONS: All three consensus definitions/classifications were associated independently with increased mortality in poisoning but with disparity between studies reporting acute kidney injury.

Acute human lethal toxicity of agricultural pesticides: a prospective cohort study.

BACKGROUND: agricultural pesticide poisoning is a major public health problem in the developing world, killing at least 250,000-370,000 people each year. Targeted pesticide restrictions in Sri Lanka over the last 20 years have reduced pesticide deaths by 50% without decreasing agricultural output. However, regulatory decisions have thus far not been based on the human toxicity of formulated agricultural pesticides but on the surrogate of rat toxicity using pure unformulated pesticides. We aimed to determine the relative human toxicity of formulated agricultural pesticides to improve the effectiveness of regulatory policy. METHODS AND FINDINGS: we examined the case fatality of different agricultural pesticides in a prospective cohort of patients presenting with pesticide self-poisoning to two clinical trial centers from April 2002 to November 2008. Identification of the pesticide ingested was based on history or positive identification of the container. A single pesticide was ingested by 9,302 patients. A specific pesticide was identified in 7,461 patients; 1,841 ingested an unknown pesticide. In a subset of 808 patients, the history of ingestion was confirmed by laboratory analysis in 95% of patients. There was a large variation in case fatality between pesticides-from 0% to 42%. This marked variation in lethality was observed for compounds within the same chemical and/or WHO toxicity classification of pesticides and for those used for similar agricultural indications. CONCLUSION: the human data provided toxicity rankings for some pesticides that contrasted strongly with the WHO toxicity classification based on rat toxicity. Basing regulation on human toxicity will make pesticide poisoning less hazardous, preventing hundreds of thousands of deaths globally without compromising agricultural needs. Ongoing monitoring of patterns of use and clinical toxicity for new pesticides is needed to identify highly toxic pesticides in a timely manner.

[Coding practice in fatal poisonings]. / Kodepraksis ved forgiftningsdødsfall.

BACKGROUND: Each year, nearly 100 deaths and more than 10,000 admissions to Norwegian hospitals can be attributed to acute poisoning from non-medical substances and drugs in supra-therapeutic doses. The aim of this study was to evaluate hospitals' routines for coding of acute poisoning deaths and to provide information on the toxic agents involved. MATERIAL AND METHODS: Medical records of deaths (at 6 Norwegian hospitals in the period 1.1.1999 -31.12.2005) due to acute poisoning were re-examined to assess accuracy of diagnosis codes. RESULTS: Acute poisoning was registered as the cause of 225 deaths in the study period. The re-evaluation concluded that 45 of these deaths had other causes. In 125 of the remaining 180 deaths, acute poisoning was only registered as a side diagnosis, although re-examination revealed it was the major contribution to death in 66 % (83 of 125) of cases. The hospitals had classified the drugs according to ATC codes in 16 % (28 of 180) of patients with acute poisoning. INTERPRETATION: The present Norwegian coding practice does not document acute poisoning deaths in hospital correctly, and registry studies based on diagnosis codes should be interpreted with care. Current registration of poisoning agents' ATC-codes is insufficient and the Norwegian version of ICD-10 alone is not suitable for classification of acute drug poisoning. Replacement of the Norwegian ICD-10 version by the original international version should be considered and/or the routines for registration of ATC-codes should be improved.

Multi-level analysis of symptoms of poison exposure reported to the Japanese Poison Information Center.

Two types of analytical multi-level approach to analyse symptoms after exposure to poisons were performed using numerical data extracted from reports received by the JAPAN POISON INFORMATION CENTER on the number "Poisoning 110" during 1998-2017. In the first approach, data collected in 2017, 2012, 2007 and 2002 were used, while in the second approach, all data collected during 1999-2017 were used. In the first approach, according to the odds ratio, the order of causative agents was industrial drugs>home drugs>general drugs and in the second approach, it was industrial drugs>foods/natural poisoning>agricultural drugs. However, in the first approach, the order based on the 95% confidence interval (CI) and profile likelihood was general drugs>home drugs>industrial drugs and in the second approach, the order based on 95% CI, profile likelihood and Wald value was agricultural drugs>foods/natural poisoning>industrial drugs. These multi-prospects were developed using a multilevel approach and the most optimized model was selected from the number of numerical data and the adaptability of fit of the multi-level logistic regression models in this report.

Multiple-dose activated charcoal in acute self-poisoning: a randomised controlled trial.

BACKGROUND: The case-fatality for intentional self-poisoning in the rural developing world is 10-50-fold higher than that in industrialised countries, mostly because of the use of highly toxic pesticides and plants. We therefore aimed to assess whether routine treatment with multiple-dose activated charcoal, to interrupt enterovascular or enterohepatic circulations, offers benefit compared with no charcoal in such an environment. METHODS: We did an open-label, parallel group, randomised, controlled trial of six 50 g doses of activated charcoal at 4-h intervals versus no charcoal versus one 50 g dose of activated charcoal in three Sri Lankan hospitals. 4632 patients were randomised to receive no charcoal (n=1554), one dose of charcoal (n=1545), or six doses of charcoal (n=1533); outcomes were available for 4629 patients. 2338 (51%) individuals had ingested pesticides, whereas 1647 (36%) had ingested yellow oleander (Thevetia peruviana) seeds. Mortality was the primary outcome measure. Analysis was by intention to treat. The trial is registered with controlled-trials.com as ISRCTN02920054. FINDINGS: Mortality did not differ between the groups. 97 (6.3%) of 1531 participants in the multiple-dose group died, compared with 105 (6.8%) of 1554 in the no charcoal group (adjusted odds ratio 0.96, 95% CI 0.70-1.33). No differences were noted for patients who took particular poisons, were severely ill on admission, or who presented early. INTERPRETATION: We cannot recommend the routine use of multiple-dose activated charcoal in rural Asia Pacific; although further studies of early charcoal administration might be useful, effective affordable treatments are urgently needed.

[Accidents with venomous and poisonous animals in Central Europe]. / Gifttierunfälle in Mitteleuropa.

Central Europe is largely safe from accidents with venomous and poisonous animals. The regions where European vipers are regularly found are shrinking. Today accidents with jellyfish and stings of venomous fish afflicted during leisure activities at the sea side play the dominant role. Life threatening accidents in Europe are mainly due to exotic snakes held in captivity. A system useful in daily medical practice is explained to classify and stage accidents due to poisonous and venomous animals. The important poisonous and venomous animals of Central Europe and the specific therapeutics, the antivenoms, are covered. The antivenom depot "Antivenin-CH" of the Swiss Toxicology Information Centre in Zurich and the MRITox in Munich with the antivenom registry Munich AntiVenom INdex (MAVIN) are presented.

[Profile of hospital admissions due to acute poisoning among children under 6 years of age in the metropolitan region of Rio de Janeiro, Brazil]. / Intoxicações exógenas em crianças menores de seis anos atendidas em hospitais da região metropolitana do Rio de Janeiro.

OBJECTIVE: To describe the profile of poisoning cases among children attended during three years at emergency hospitals in the metropolitan area of Rio de Janeiro, Brazil. METHODS: All confirmed or suspected poisoning cases, due to drugs and biological substances; organic solvents and hydrocarbons; chemical products; carbon monoxide and other gases; and pesticides, were collected. RESULTS: 1,574 cases of poisoning in children up to 5 years of age were detected. Around 40% of the cases involved chemical products of domestic use, 35% were caused by drugs, and 15% by pesticides. More than half of pesticide poisonings involved the 'chumbinho', an illegal product sold as a rodenticide, and usually including in its formulation a carbamate. Distribution of agents varied significantly by gender, the relative frequency of poisonings due to drugs and 'chumbinho' being higher among females than males. Participation of chemical products of domestic use decreased with age, but the role of drugs increased as agents of poisoning. During the observation period there was no significant reduction in the total number of annual cases. CONCLUSION: Supporting the expansion of the network of Poison Control Centers, developing intervention for the production of safer packaging devices for drugs chemical products, suppressing the illegal commerce of 'chumbinho', and fostering health education activities might contribute to modify this situation.

Secular trends in poisonings leading to hospital admission among Finnish children and adolescents between 1971 and 2005.

OBJECTIVE: To investigate the secular trends in childhood poisonings leading to hospitalization in Finland. STUDY DESIGN: All children and adolescents age 0 to 19 years hospitalized in Finland with the primary diagnosis of poisoning between 1971 and 2005 were identified using the International Classification of Diseases. RESULTS: During the study period, there were 41 862 hospitalizations with 96 427 hospital bed days for poisoning in 38 582 children and adolescents. The incidence of hospitalization declined from 91.3 admissions per 100 000 person-years in boys and 105.2 per person-years in girls in 1971 to 64.8 in boys and 83.5 in girls in 2005. In the 0- to 4-year age group, admissions declined by 51%. Hospitalizations for alcohol poisoning increased 1.7-fold (95% confidence interval = 1.4 to 2.2) in boys and 2.4-fold (95% confidence interval = 1.8 to 3.3) in girls. Alcohol poisoning was the primary diagnosis in 53% of those in the 10- to 14-year age group. CONCLUSIONS: Poisoning remains an important cause of morbidity in Finnish children and adolescents despite the decreased overall incidence of poisonings leading to hospitalization between 1971 and 2005. The increasing trend of hospital admissions for alcohol poisoning, especially in 10- to 14-year-olds, is noteworthy. Effective primary prevention programs and adult supervision should be targeted at reducing alcohol consumption and alcohol-related poisonings in youth.

Acute pesticide poisoning: a proposed classification tool.

Cases of acute pesticide poisoning (APP) account for significant morbidity and mortality worldwide. Developing countries are particularly susceptible due to poorer regulation, lack of surveillance systems, less enforcement, lack of training and inadequate access to information systems. Previous research has demonstrated wide variability in incidence rates for APP. This is possibly due to inconsistent reporting methodology and exclusion of occupational and non-intentional poisonings. The purpose of this document is to create a standard case definition to facilitate the identification and diagnosis of all causes of APP, especially at the field level, rural clinics and primary health-care systems. This document is a synthesis of existing literature and case definitions that have been previously proposed by other authors around the world. It provides a standardized case definition and classification scheme for APP into categories of probable, possible and unlikely/unknown cases. Its use is intended to be applicable worldwide to contribute to identification of the scope of existing problems and thus promote action for improved management and prevention. By enabling a field diagnosis for APP, this standardized case definition may facilitate immediate medical management of pesticide poisoning and aid in estimating its incidence.

A clinical decision aid for triage of children younger than 5 years and with organophosphate or carbamate insecticide exposure in developing countries.

STUDY OBJECTIVE: Unintentional pediatric exposure to insecticides is common in developing countries. A clinical decision aid could guide early triage decisionmaking. METHODS: Study design was prospective observational data collection in a specialty poisoning hospital in Cairo, Egypt. Patients were children 2 months to 59 months of age, without pretreatment, presenting within 2 hours of an exposure to an organophosphate or carbamate insecticide. A resource-requiring course was defined as any occurrence of hypoxia, use of atropine or obidoxime, use of ICU care, or death. The goal of analysis was derivation of a clinical decision aid to predict a resource-requiring course with 100% sensitivity. RESULTS: During the 21-month study, 197 children 2 months to 59 months of age exposed to an organophosphate or carbamate insecticide were treated at the center. One hundred two of these children met the study inclusion criteria: 95 had parental consent and completed the study observation period of which 65 used resources (4 died). All patients who ultimately met resource-requiring criteria initially did so at arrival. Pinpoint pupil alone identified 63 of 65 of these patients yet wrongly identified only 5 of 30 minimally ill patients. Pinpoint pupil or diarrhea identified 65 of 65 patients with a resource-requiring course while identifying 7 of 30 patients with a non-resource-requiring course (sensitivity 1.00; 95% confidence interval 0.95 to 1.00; specificity 0.77; 95% confidence interval 0.58 to 0.90). CONCLUSION: Using 2 features, pinpoint pupils and diarrhea, we identified at presentation all patients who ultimately had a course using medications or advanced resources. According to this preliminary study, symptoms occur rapidly, so using an early triage aid may be feasible. A validation study is necessary.