Fomepizole use reported to United States Poison Centers from 2010 to 2021.

BACKGROUND: The diagnosis of toxic alcohol poisoning is often based on clinical presentation and nonspecific surrogate laboratory studies due to limited testing availability. Fomepizole is the recommended antidote and often administered empirically. The objective of this study is to identify substances that mimic toxic alcohols and compare key clinical factors between toxic alcohol and non-toxic alcohol exposures when fomepizole was administered. METHODS: This study was a retrospective evaluation using the National Poison Data System from January 1, 2010 through December 31, 2021. Exposures were included if fomepizole was administered. Toxic alcohol exposures had ethylene glycol or methanol as a coded substance. For exposures not coded as a toxic alcohol, the first substance was described. Paracetamol (acetaminophen) exposures from 2020 and 2021 were excluded. RESULTS: Fomepizole was reportedly used 25,110 times over 12 years. Use increased from 1,955 in 2010 to 2,710 in 2021. Most administrations were for reported toxic alcohol poisoning (60 percent) but use in reported non-toxic alcohol poisoning was greater starting in 2020. Toxic alcohol exposures were older (43.3 versus 39.8 years; P < 0.001) and more likely male (65.7 percent versus 58.2 percent). Level of care was mostly a critical care unit (67.7 percent), which was less common in toxic alcohol (63.3 percent) than non-toxic alcohol exposures (74.2 percent). The most common non-toxic alcohol substances were ethanol (24.9 percent) or an unknown drug (17.5 percent). Acidosis, increased creatinine concentration, anion gap, and osmolal gap, and kidney failure were coded in a lower proportion of toxic alcohol exposures than non-toxic alcohol exposures (P < 0.001). DISCUSSION: The inability to provide rapid clinical confirmation of toxic alcohol poisoning results in the empiric administration of fomepizole to many patients who will ultimately have other diagnoses. Although fomepizole is relative well tolerated we estimated that this practice costs between $1.5 to $2.5 million. The major limitations of this work include the biases associated with retrospective record review, and the inability to confirm the exposures which may have resulted in allocation error. CONCLUSION: Most fomepizole use was for a presumed toxic alcohol. This recently shifted to greater use in likely non-toxic alcohol poisoning. Key difference between the groups suggest fomepizole administration was likely due to the difficulty in diagnosis of toxic alcohol poisoning along with the efficacy and safety of fomepizole. Increased toxic alcohol laboratory testing availability could improve timely diagnosis, reserving fomepizole use for toxic alcohol poisoning.

Glucagon-Like Peptide-1 Receptor Agonist Cases Reported to United States Poison Centers, 2017-2022.

INTRODUCTION: Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are a class of medications for management of diabetes and obesity. The objective of this study is to characterize the epidemiology of GLP-1RA cases reported to US poison centers. METHODS: We analyzed cases involving a GLP-1RA reported to the National Poison Data System during 2017-2022. RESULTS: There were 5,713 single-substance exposure cases reported to US poison centers involving a GLP-1RA. Most cases were among females (71.3%) and attributable to therapeutic errors (79.9%). More than one-fifth (22.4%) of cases were evaluated in a healthcare facility, including 0.9% admitted to a critical care unit and 4.1% admitted to a non-critical care unit. Serious medical outcomes were described in 6.2% of cases, including one fatality. The rate of cases per one million US population increased from 1.16 in 2017 to 3.49 in 2021, followed by a rapid increase of 80.9% to 6.32 in 2022. Trends for rates of serious medical outcomes and admissions to a healthcare facility showed similar patterns with 129.9% and 95.8% increases, respectively, from 2021 to 2022. CONCLUSIONS: Most GLP-1RA cases reported to US poison centers were associated with no or minimal effects and did not require referral for medical treatment; however, a notable minority of individuals experienced a serious medical outcome or healthcare facility admission. The rate of reported cases increased during the study period, including an 80.9% increase from 2021 to 2022. Opportunities exist to improve provider and patient awareness of the adverse effects of these medications.

Assessing the frequency and types of errors involved in the use of a modified intravenous N-acetylcysteine protocol for acetaminophen overdose.

BACKGROUND: Acetaminophen overdose is a leading cause of acute liver failure in developing countries. N-acetylcysteine (NAC) is a highly effective antidote for acetaminophen hepatotoxicity, typically initiated in the emergency department. Due to a known high rate of errors with the standard three-bag IV NAC protocol, in 2019, the Ontario Poison Center changed to a modified 3% IV NAC one-bag protocol. This study was undertaken to determine the frequency and types of errors associated with the use of this protocol. METHODS: Data were gathered via chart review of Ontario Poison Centre electronic medical record cases identified as receiving IV NAC for acetaminophen overdose between August 1 and September 30, 2022. 218 total charts were identified, and 188 were deemed eligible based on inclusion and exclusion criteria. RESULTS: Errors were identified in 25% of charts, consisting of dosing errors in 11.7%, stopping errors in 9.0%, initiation errors in 3.7%, and interruptions in therapy in 3.2%. Dosing errors were the most common type of error (44.4%), with overdoses occurring three times more than underdoses. Errors were identified at 39% of geographic locations in the charts reviewed, with similar frequency in Ontario, Manitoba, and Nunavut. Clinical outcomes were similar in charts with and without errors. INTERPRETATION: The rate of errors identified with this 3% IV NAC one-bag protocol is lower than reported for the standard three-bag protocol, but remains high due to dosing errors. Previously reported issues with prolonged interruptions in therapy with the standard three-bag protocol were low with the current 3% one-bag protocol. Although severe outcomes are rare, IV NAC overdose can be fatal. Identifying local factors in emergency departments that can contribute to administration errors (i.e., dose calculation, pump programming issues) can enhance the safety of this important antidote.

RéSUMé: CONTEXTE: La surdose d'acétaminophène est l'une des principales causes d'insuffisance hépatique aiguë dans les pays en développement. La N-acétylcystéine (NAC) est un antidote très efficace contre l'hépatotoxicité de l'acétaminophène, généralement initiée au service des urgences. En raison d'un taux élevé connu d'erreurs avec le protocole NAC standard à 3 sacs IV, en 2019, le Centre antipoison de l'Ontario a adopté un protocole NAC à 1 sac IV modifié à 3 %. Cette étude a été entreprise pour déterminer la fréquence et les types d'erreurs associées à l'utilisation de ce protocole. MéTHODES: Les données ont été recueillies au moyen d'un examen des dossiers médicaux électroniques du Centre antipoison de l'Ontario qui ont reçu une dose IV de NAC pour une surdose d'acétaminophène entre le 1 août et le 30 septembre 2022. 218 cartes au total ont été identifiées, et 188 ont été jugées admissibles en fonction de critères d'inclusion et d'exclusion. RéSULTATS: Des erreurs ont été relevées dans 25 % des dossiers, soit des erreurs de dosage dans 11,7 %, des erreurs d'arrêt dans 9,0 %, des erreurs d'initiation dans 3,7 % et des interruptions du traitement dans 3,2 %. Les erreurs de dosage étaient le type d'erreur le plus courant (44,4 %), les surdoses étant trois fois plus fréquentes que les sous-doses. Des erreurs ont été relevées à 39 % des emplacements géographiques dans les cartes examinées, avec une fréquence similaire en Ontario, au Manitoba et au Nunavut. Les résultats cliniques étaient similaires dans les tableaux avec et sans erreurs. INTERPRéTATION: Le taux d'erreurs identifiées avec ce protocole à un sac NAC IV à 3 % est inférieur à celui du protocole standard à 3 sacs, mais reste élevé en raison d'erreurs de dosage. Les problèmes précédemment rapportés avec les interruptions prolongées du traitement avec le protocole standard à 3 sacs étaient faibles avec le protocole actuel à 3% à un sac. Bien que les résultats graves soient rares, une surdose de NAC IV peut être fatale. L'identification de facteurs locaux dans les services d'urgence qui peuvent contribuer aux erreurs d'administration (c.-à-d. le calcul de la dose, les problèmes de programmation de la pompe) peut améliorer l'innocuité de cet antidote important.

Quenching thirst with poison? Paradoxical effect of anticancer drugs.

Anticancer drugs have been developed with expectations to provide long-term or at least short-term survival benefits for patients with cancer. Unfortunately, drug therapy tends to provoke malignant biological and clinical behaviours of cancer cells relating not only to the evolution of resistance to specific drugs but also to the enhancement of their proliferation and metastasis abilities. Thus, drug therapy is suspected to impair long-term survival in treated patients under certain circumstances. The paradoxical therapeutic effects could be described as 'quenching thirst with poison', where temporary relief is sought regardless of the consequences. Understanding the underlying mechanisms by which tumours react on drug-induced stress to maintain viability is crucial to develop rational targeting approaches which may optimize survival in patients with cancer. In this review, we describe the paradoxical adverse effects of anticancer drugs, in particular how cancer cells complete resistance evolution, enhance proliferation, escape from immune surveillance and metastasize efficiently when encountered with drug therapy. We also describe an integrative therapeutic framework that may diminish such paradoxical effects, consisting of four main strategies: (1) targeting endogenous stress response pathways, (2) targeting new identities of cancer cells, (3) adaptive therapy- exploiting subclonal competition of cancer cells, and (4) targeting tumour microenvironment.

Clinical Spectrum of Mercury Poisoning in India: Case-series from a Poison Control Center.

BACKGROUND: Mercury is a naturally occurring heavy metal that finds wide application in industrial and household settings. It exists in three chemical forms which include elemental (Hg0 ), inorganic mercurous (Hg+) or mercuric (Hg++) salts, and organic compounds. All forms are highly toxic, particularly to the nervous, gastrointestinal, and renal systems. Common circumstances of exposure include recreational substance use, suicide or homicide attempts, occupational hazards, traditional medicines, and endemic food ingestions as witnessed in the public health disasters in Minamata Bay, Japan and in Iraq. Poisoning can result in death or long-term disabilities. Clinical manifestations vary with chemical form, dose, rate, and route of exposure. AIMS AND OBJECTIVES: To summarize the incidence of mercury poisoning encountered at an Indian Poison Center and use three cases to highlight the marked variations observed in clinical manifestations and long-term outcomes among poisoned patients based on differences in chemical forms and routes of exposure to mercury. MATERIALS AND METHODS: A structured retrospective review of the enquiry-database of the Poison Information Center and medical records of patients admitted between August 2019 and August 2021 in a tertiary care referral center was performed. All patients with reported exposure to mercury were identified. We analyzed clinical data and laboratory investigations which included heavy metal (arsenic, mercury, and lead) estimation in whole blood and urine samples. Additionally, selected patients were screened for serum voltage-gated potassium ion channels (VGKC)- contactin-associated protein-like 2 (CASPR2) antibodies. Three cases with a classical presentation were selected for detailed case description. RESULTS: Twenty-two cases were identified between August 2019 and August 2021. Twenty (91%) were acute exposures while two (9%) were chronic. Of these, three representative cases have been discussed in detail. Case 1 is a 3.5-year-old girl who was ought to the emergency department with suspected elemental-mercury ingestion after biting a thermometer. Clinical examination was unremarkable. Chest and abdominal radiography revealed radiodense material in the stomach. Subsequent serial radiographs documented distal intestinal transit of the radiodense material. The child remained asymptomatic. This case exemplifies the largely nontoxic nature of elemental mercury ingestion as it is usually not absorbed from the gastrointestinal tract. Case 2 is a 27-year-old lady who presented with multiple linear nodules over both upper limbs after receiving a red intravenous injection for anemia. Imaging revealed metallic-density deposits in viscera and bones. Nodular biopsy was suggestive of mercury granulomas. A 24-hour urine mercury levels were elevated. She was advised chelation therapy with oral dimercaptosuccinic acid (DMSA). Case 3 is a 22-year-old lady who presented with acrodynia, neuromyotonia, tremulousness, postural giddiness, tachycardia, and hypertension for 2 months, associated with intractable, diffuse burning pain over the buttocks and both lower limbs, 1 month after completing a 3-week course of traditional medications for polycystic ovarian syndrome. A 24-hour urine normetanephrine levels and mercury levels were markedly elevated. Serum anti-VGKC antibodies were present. She was treated with glucocorticoids and oral DMSA with a favorable clinical response. CONCLUSIONS: The clinical manifestations of mercury toxicity are highly variable depending on the source, form, and route of mercury exposure and are related to its toxicokinetics.

The Role of Activated Charcoal in Prehospital Care.

Background: Administration of a single-dose activated charcoal (SDAC) is an effective method used for gastric decontamination and for other types of poisoning and overdose. This is only true when given within the first hour of poison ingestion as the effectivity of SDAC reduces over time. In addition, generally, not all patients are able to avail treatment within the specified period. Hence, multi-dose activated charcoal is regarded as a solution to a delayed process, although, no proof outweighs the use of SDAC. Objective: This study aimed to review and assess the adequacy of the past and current use of AC. The author also aimed to offer recommendations believed to be the best method to consider for prehospital care. Methods: The author conducted 6,337 online literature searches for this review, wherein seven papers met eligibility criteria for inclusion and analysis. Results: In this review, routine administration of AC in poisoning was found not related to the duration of hospital stay nor any other subsequent outcomes following poison ingestion. Further, this review did not establish that administration of AC could improve patient's clinical outcome. Further research and clinical trials is required to determine the efficacy of this therapy to appropriate patients in the prehospital setting. Conclusion: Activated charcoal can be used to treat highly acute to life-threatening poisoning if it is administered within the first hour of ingestion. Further studies would be necessary to investigate if this would affect clinical outcome..

Novel Pyrido[2',1':2,3]imidazo[4,5-c]quinoline Derivative Selectively Poisons Leishmania donovani Bisubunit Topoisomerase 1 to Inhibit the Antimony-Resistant Leishmania Infection in Vivo.

The unique bisubunit structure of Leishmania donovani topoisomerase 1B (LdTop1) is a potential drug target in the parasites unlike the monomeric Top1 from its human host counterpart. Here, we report the design, synthesis, and validation of a chimeric pyrido[2',1':2,3]imidazo[4,5-c]quinoline derivative (C17) as a novel antileishmanial agent that poisons topoisomerase 1-DNA covalent complexes (LdTop1cc) inside the parasites and inhibits Top1 religation activity both in the drug sensitive and antimony-resistant L. donovani clinical isolates. Importantly, the human Top1 is not sensitive to C17. Further, C17 overcomes the chemical instability of camptothecin (CPT) by generating persistent LdTop1cc-induced DNA breaks inside the parasites even after 12 h of drug removal. Intraperitoneal administration of C17 results in marked reduction of the Leishmania amastigotes from the infected spleen and liver of BALB/c mice. C17 confers a host protective immune-response up-regulating the Th1 cytokines facilitating parasite clearance which can be exploited for treating drug-resistant leishmaniasis.

Clinical characteristics and outcomes using dexmedetomidine in nonintubated patients: A poison center observational study.

PURPOSE: Dexmedetomidine is a central α2 agonist commonly used on intubated patients. It is increasingly being used off-label in nonintubated agitated patients. We sought to determine the overall clinical course, adverse effects, and need for subsequent mechanical ventilation in toxicology patients after treatment with dexmedetomidine. METHODS: This was a retrospective cohort study conducted by chart review of electronic records from the Virginia Poison Control Center from January 1, 2019 to February 4, 2022. Inclusion criteria consisted of all poison center cases where dexmedetomidine was used. The primary outcome was the presence or absence of clinical improvement following dexmedetomidine use. Secondary outcomes included adverse effects, subsequent intubation, or death. RESULTS: During this study period, there were 220 cases in which dexmedetomidine was used to treat agitation. After exclusions, 70 cases were analyzed. The categories included antimuscarinic (n = 19), polysubstance (n = 16), sedative withdrawal (n = 10), unknown agitation (n = 7), sympathomimetic (n = 5), baclofen withdrawal (n = 3), unknown ingestion (n = 3), sedative/hypnotic (n = 2), antipsychotic (n = 2), hallucinogenic (n = 2), and opioid withdrawal (n = 1). Clinical improvement occurred in 62 of 70 patients (89%). There were no deaths. A total of 4 patients were intubated after starting dexmedetomidine, 2 for refractory agitation and 2 for hypoxia after aspiration. CONCLUSION: Global clinical improvement was observed in the agitated toxicology patients administered dexmedetomidine. There was one case of intubation secondary to oversedation. Dexmedetomidine could be a useful adjunctive treatment for agitated toxicologic patients but should be studied further before routinely used.

Dedicated nursing care pathway improved management of opioid-poisoned patients in the emergency department: A before-after observational study.

OBJECTIVE: Opioid overdose is increasing and accounts for two-thirds of poisoning deaths. Opioid induced respiratory depression is life-threatening and can be under-recognised even in the hospital setting. We aimed to evaluate the effect of a care pathway on the management of opioid-poisoned patients. METHODS: This is a before-after observational study following the introduction of a nursing care pathway for opioid-poisoned patients presenting to ED. Medical records were retrospectively reviewed pre (6-month period 1 year prior) and post (9-month period following) the introduction of the pathway. The primary outcome was the proportion of documented episodes of respiratory depression (respiratory rate <10 or oxygen saturation <93% on room air) receiving naloxone. Secondary outcomes were time to naloxone, number of documented observations (first 4 h) and length of stay. RESULTS: There were 111 patients included in the study, 61 pre-intervention and 50 post-intervention (35 followed the pathway). A significantly larger proportion of patients received naloxone for respiratory depression when the pathway was used (134/200 [67%] vs 34/118 [29%], difference 38%, 95% CI 28-48%). The median time to naloxone was similar (pathway 28.5 min vs no pathway 35 min, difference -6.5 min, 95% CI -19 to 12 min). Documentation increased when the pathway was used (12.0 observations/presentation vs 7.5 observations/presentation, difference 4.5 observations/patient, 95% CI 2.1-7.0 observations/patient). Length of stay was similar (pathway 16.7 h vs no pathway 15.3 h, difference 1.4 h, 95% CI -2.4 to 5.9 h). CONCLUSIONS: Following the introduction of a dedicated opioid poisoning nursing care pathway, naloxone delivery and observation documentation increased. A care pathway may improve ED management of opioid poisoning.

Home management of pediatric sulfonylurea ingestions.

INTRODUCTION: Sulfonylureas are oral antidiabetic medications that act by stimulating insulin release from pancreatic beta cells. Unintentional pediatric ingestions may result in hypoglycemia. While guidelines often recommend up to a 24-hour hospital observation period for any ingestion, the Oregon Poison Center has historically managed select patients at home. This study aimed to describe outcomes of home-managed pediatric sulfonylurea exposures and characteristics of ingestions that are appropriate for home monitoring. METHODS: This is a retrospective chart review of pediatric (≤5 years) sulfonylurea ingestions in a single poison center over a 19-year period (2002-2020). We reviewed 491 individual cases for age, ingestion quantity, witnessed or unwitnessed ingestions, hypoglycemia (<60 mg/dL), disposition, and severe events (seizures or coma). We excluded cases in which missing pills were later found or another agent was identified. RESULTS: Of 474 patients meeting inclusion criteria, 135 (28%) were initially managed at home. Of these, 115 (85.3%) were ingestions of ≤1 tablet, where 68 (59%) were witnessed and 47 (41%) were unwitnessed. One hundred twenty five (92.6%) of these patients were successfully monitored at home, with 10 (7%) ultimately referred to a healthcare facility (HCF). Symptoms of hypoglycemia, measured glucose on home meter <60 mg/dL, fluctuations in monitored glucose, or parental concern were indications for HCF referral. Of those referred, 5 (4%) developed uncomplicated, asymptomatic hypoglycemia. Two of these received octreotide, at the discretion of the treating physician. No patients developed seizures or coma. DISCUSSION: We report 135 pediatric sulfonylurea ingestions managed with initial home monitoring, the majority of which were successfully monitored at home without any reported adverse events. Ten patients "failed home monitoring," as defined by referral to a healthcare facility. Of these, five developed hypoglycemia, though no patients developed symptoms or serious adverse events. CONCLUSION: Our findings support home observation for children ≤5 years with small ingestions of second-generation sulfonylureas.

Poisonings with ADHD medication in children under the age of 5 years in Australia: a retrospective study, 2004-2019.

OBJECTIVE: To describe the temporal relationships in attention-deficit hyperactivity disorder (ADHD) medication poisoning exposures in children; describe patient demographics, medications involved, poisoning exposure reasons and disposition. DESIGN: A population-based, retrospective cohort study of calls to Australia's largest Poisons Information Centre. Poisoning exposure counts and dispensing-adjusted rates were modelled with Poisson, quasi-Poisson and negative binomial regression where appropriate. SETTING: Calls to the New South Wales Poisons Information Centre and dispensings on the Pharmaceutical Benefits Scheme. PATIENTS: Children under the age of 5 years. RESULTS: There were 1175 poisoning exposures to ADHD psychostimulants, 2004-2019; averaging 73 per year. Accidental poisonings accounted for 94% of cases. Methylphenidate was most frequently implicated (63%). Thirty-four per cent of cases were referred to hospital and a further 21% of calls were made by hospital staff. Poisoning exposure counts for all ADHD psychostimulants increased by 2.7% (95% CI=0.42% to 4.9%) per year; however, this differed by agent. Methylphenidate poisoning exposures increased by 5.2% per year (95% CI=4.3% to 6.1%), lisdexamfetamine increased by 62% per year (95% CI=48% to 76%), while dexamphetamine poisoning exposures decreased by 5.5% per year (95% CI=-9.5% to -1.4%). These trends are reflected in the number of dispensings; however, dispensings increased at a faster rate than exposures. When poisoning exposures were expressed as dispensing-adjusted rates, there was a 16% decrease (95% CI=-20% to -13%) per year. CONCLUSIONS: ADHD medication use has increased, associated with an increased number of paediatric poisoning exposures. However, poisoning exposures per dispensed prescription has decreased. The majority of cases required hospitalisation, indicating the need for further poisoning prevention strategies.

Kratom exposures managed by the British Columbia poison centre, 2012-2019: a descriptive analysis.

BACKGROUND: Kratom, a plant indigenous to Southeast Asia, which has been used both recreationally and in the treatment of pain and opioid dependence, has received little scrutiny in the United States and almost none in Canada. We analyzed calls to the British Columbia poison centre to describe caller-declared exposures to kratom and the acute health effects of these exposures. METHODS: For this descriptive analysis, we accessed electronic records, including transcriptions and extracted variables, of calls specifying kratom exposure managed by the BC Drug and Poison Information Centre (DPIC) from 2012 to 2019. We describe changes in case numbers, reasons for exposure, concurrent drug exposures and clinical outcomes over the study period. RESULTS: We identified 32 cases during the study period. In 23 cases (72%), the DPIC was consulted by a health care worker. Case numbers increased from 0 in 2012 to 9 in 2019. Numbers were highest for males in their 20s (n = 17, 53%). A total of 27 cases (84%) involved ingestion, with online distributors and local stores named as sources of procurement. A concurrent drug exposure was identified in 13 (41%) cases. There were no deaths; in 1 case, the exposed individual was intubated to manage agitation following kratom withdrawal. INTERPRETATION: We observed a steady increase in kratom-related poison centre calls from 2012 to 2019, especially in young adult males. Rising call numbers may reflect increasing availability of kratom and may be a consequence of BC's opioid crisis, with kratom used by some to lessen symptoms of opioid withdrawal.

Topoisomerase I poison-triggered immune gene activation is markedly reduced in human small-cell lung cancers by impairment of the cGAS/STING pathway.

BACKGROUND: Current immunotherapy strategies have contrasting clinical results in human lung cancer patients as small-cell lung cancers (SCLC) often show features of immunological cold tumours. Topoisomerase 1 (TOP1) poisons are effective antitumor drugs with good efficacy against lung cancers. METHODS: We used molecular, genetic and bioinformatic approaches to determine the mechanism of micronuclei formation induced by two TOP1 poisons in different human cancer cells, including SCLC cell lines. RESULTS: TOP1 poisons stimulate similar levels of micronuclei in all tested cell lines but downstream effects can vary markedly. TOP1 poisons increase micronuclei levels with a mechanism involving R-loops as overexpression of RNaseH1 markedly reduces or abolishes both H2AX phosphorylation and micronuclei formation. TOP1 poison-induced micronuclei activate the cGAS/STING pathway leading to increased expression of immune genes in HeLa cells, but not in human SCLC cell lines, mainly due to lack of STING and/or cGAS expression. Moreover, the expression of STING and antigen-presenting machinery genes is generally downregulated in patient tumours of human lung cancer datasets. CONCLUSIONS: Altogether, our data reveal an immune signalling mechanism activated by TOP1 poisons, which is often impaired in human SCLC tumours.

Metabolic Acidosis: Differentiating the Causes in the Poisoned Patient.

Numerous drugs and toxins can cause metabolic acidosis. The treating clinician should be aware of the many compounds that can produce metabolic acidosis following an accidental exposure, an overdose, or with therapeutic use. Awareness and comprehension of those substances associated with metabolic acidosis will facilitate the diagnosis and treatment of poisoned patients.

Heroin and fentanyl overdose deaths among cases age 50+ in the National Poison Data System, 2015-2020.

CONTEXT: Illicit opioid use and heroin treatment admissions among individuals age 50+ have increased. Little research has, however, examined correlates of illicit opioid overdose deaths in this age group before or during the COVID-19 pandemic or the healthcare services used in these cases. METHODS: The sample included illicit opioid (heroin, fentanyl, or other synthetic, nonpharmaceutical opioids) poisoning cases age 50+ (N = 5576) in the National Poison Data System (NPDS), 2015-2020. Using descriptive statistics and logistic regression models, we report changes in overdose death rates during the study period and associations of death with healthcare service use, naloxone administration, and clinical and demographic characteristics. RESULTS: The 6-year average overdose death rate from illicit opioids among those age 50+ was 2.9%, increasing from 1.4% in 2015 to 4.0% in 2019 and 3.6% in 2020. Logistic regression results showed that exposure year was not a significant factor in the odds of overdose death; however, odds were significantly higher among cases that were not managed at any healthcare facility (HCF) (adjusted odds ratio [AOR] = 4.60, 95% confidence interval [CI] = 3.19-6.63) and lower among those who received naloxone therapy (AOR = 0.64, 95% CI = 0.45-0.92). The odds of death were also higher among cases involving exposure at own or another's home and co-use of prescription opioids, alcohol, and other illicit drugs. CONCLUSIONS: Although the NPDS did not show increases in illicit opioid overdose death rates among cases age 50+ in 2020 compared to 2019, overdose deaths were greater among cases that were not managed at HCF and did not receive naloxone therapy. Many appear to have died before they received any intervention to prevent death. Improved access to healthcare services and social support and access to naloxone therapy for older adults with opioid use problems are needed.

Role of KSP Inhibitors as Anti-cancer Therapeutics: An Update.

Regardless of the growing discovery of anticancer treatments targeting cancer-specific pathways, cytotoxic therapy still maintained its abundant clinical significance because tumours harbor a greater population of actively dividing cells than normal tissues. Conventional anti-mitotic agents or microtubule poisons acting on the major mitotic spindle protein tubulin have been effectively used in clinical settings for cancer chemotherapy over the last three decades. However, the use of these drugs is associated with limited clinical utility due to serious side effects such as debilitating and dose-limiting peripheral neuropathy, myelosuppression, drug resistance, and allergic reactions. Therefore, research initiatives have been undertaken to develop novel microtubule motor proteins inhibitors that can potentially circumvent the limitations associated with conventional microtubule poisons. Kinesin spindle proteins (KSP) belonging to the kinesin-5 family play a crucial role during mitosis and unregulated cell proliferation. Evidence from preclinical studies and different phases of clinical trials have presented kinesin spindle protein as a promising target for cancer therapeutics. Kinesin spindle protein inhibitors causing mitosis disruption without interfering with microtubule dynamics in non-dividing cells offer a potential therapeutic alternative for the management of several major cancer types and are devoid of side effects associated with classical anti-mitotic drugs. This review summarizes recent data highlighting progress in the discovery of targeted KSP inhibitors and presents the development of scaffolds, structure-activity relationships, and outcomes of biological and enzyme inhibition studies. We reviewed the recent literature reports published over the last decade, using various electronic database searches such as PubMed, Embase, Medline, Web of Science, and Google Scholar. Clinical trial data till 2021 was retrieved from ClinicalTrial.gov. Major chemical classes developed as selective KSP inhibitors include dihydropyrimidines, ß-carbolines, carbazoles, benzimidazoles, fused aryl derivatives, pyrimidines, fused pyrimidines, quinazolines, quinolones, thiadiazolines, spiropyran, and azobenzenes. Drugs such as filanesib, litronesib, ispinesib have entered clinical trials; the most advanced phase explored is Phase II. KSP inhibitors have exhibited promising results; however, continued exploration is greatly required to establish the clinical potential of KSP inhibitors.

Clinical effects and factors associated with adverse clinical outcomes of hymenopteran stings treated in a Thai Poison Centre: a retrospective cross-sectional study.

OBJECTIVE: To describe clinical effects and outcomes of hymenopteran stings and to explore the non-laboratory factors associated with adverse clinical outcomes, a composite outcome including death, respiratory failure requiring intubation, acute kidney injury (AKI) requiring dialysis and hypotension requiring vasopressor use. METHODS: A retrospective cross-sectional study was performed at the Ramathibodi Poison Center, a poison centre of a tertiary care hospital in Thailand. All cases of hymenopteran sting consultations from January 2015 to June 2019 were consecutively enrolled, and charts were reviewed. Demographics, initial clinical characteristics and outcomes were collected. Factors associated with adverse clinical outcome were explored. RESULTS: One hundred and fourteen hymenopteran stings cases (wasp 48%, bee 33%, hornet 14% and carpenter bee 8.8%) were included (median age, 36.5 years (interquartile range 9-55); male 63%). The prevalence of adverse clinical outcomes was 12.3% (95%CI 6.88-12.8). At initial presentation, 100% of cases had local skin reactions, 11.4% were clinical anaphylaxis, and 8% had red urine. Adverse clinical outcomes included death (n = 10), respiratory failure requiring intubation (n = 9), AKI requiring dialysis (n = 6) and hypotension requiring vasopressor use (n = 2). None of the patients with carpenter bee or hornet stings developed adverse clinical outcomes. In univariable analysis, urticaria, wheezing, red urine, wasp sting and sting number > 10 were significantly associated with adverse clinical outcomes. In multivariable analysis, red urine (adjusted OR 11.1 (95% CI 1.57-216)), wheezing (adjusted OR 16.7 (95% CI 1.43-402)) and a number of stings > 10 (adjusted OR 21.5 (95% CI2.13-2557)) were significant. CONCLUSIONS: Adverse clinical outcomes in hymenopteran stings were not uncommon among cases inquiring to a national Thai poison centre. At initial presentation, red urine, wheezing and a number stings >10 were significantly associated with adverse clinical outcomes. Larger epidemiologic studies are required to confirm these associations.

Indigenous venomous snakebites in Switzerland: analysis of reports to the National Poisons Information Centre over 22 years.

INTRODUCTION: Two venomous snakes, the asp viper (Vipera aspis) and the common adder (Vipera berus) are native to Switzerland. Bites by both vipers cause mainly local effects, but systemic envenomation is possible. METHODS: We analysed all calls concerning indigenous venomous snakebites recorded at the Swiss National Poisons Information Centre between 1997 and 2018, including all cases with identification by a herpetologist, and/or with compatible symptoms and circumstances of the exposure. RESULTS: During the study period, 1,364 cases concerned snakebites. One third (466; 34%) were attributed to indigenous vipers. In 243 (52%) patients, medical follow-up information was available, with good causality between exposure and symptoms in 219 (90%) patients. Vipera aspis was identified in 77 of the cases (35%), Vipera berus in 54 (25%), and not further specified vipers in 88 (40%). In over two thirds of the 219 cases (155, 71%) adult patients were affected (male 109, female 46; median age 43 years [range 16-90]). Sixty-four patients were children (male 47, female 16; median age 11 years [range 1.3-15.9]). The highest occurrence of bites was in the summer months. In the majority of patients, the clinical course was mild (94; 43%) or moderate (80; 36%); a lower proportion was either asymptomatic (17; 8%) or exhibited severe symptoms (28; 13%). There were no fatalities reported. The most frequent symptoms were local effects at the bite site with mild (100; 46%) to moderate (56; 25%) swelling, pain (65; 30%) and redness (51; 23%). Gastrointestinal symptoms including nausea (31; 14%), vomiting (47; 22%) and abdominal pain (25; 11%) were also common. Other systemic symptoms included cardiovascular effects (e.g., hypotension (20; 9%) or shock [6; 3%]), neurotoxicity (e.g., visual impairment [5; 2.3%]) and haematotoxicity (e.g., coagulopathy [11; 5%]). Seven (3.2%) patients developed anaphylactic reactions. Antivenom was administered in only 20% (24 with moderate and 19 with severe symptoms) with good resolution of symptoms. The mean duration of hospitalization was 2 days (0-12 days). CONCLUSION: Snakebites in Switzerland can result in severe symptoms, sometimes necessitating antivenom treatment.

From Poison to Promise: The Evolution of Tetrodotoxin and Its Potential as a Therapeutic.

Tetrodotoxin (TTX) is a potent neurotoxin that was first identified in pufferfish but has since been isolated from an array of taxa that host TTX-producing bacteria. However, determining its origin, ecosystem roles, and biomedical applications has challenged researchers for decades. Recognized as a poison and for its lethal effects on humans when ingested, TTX is primarily a powerful sodium channel inhibitor that targets voltage-gated sodium channels, including six of the nine mammalian isoforms. Although lethal doses for humans range from 1.5-2.0 mg TTX (blood level 9 ng/mL), when it is administered at levels far below LD50, TTX exhibits therapeutic properties, especially to treat cancer-related pain, neuropathic pain, and visceral pain. Furthermore, TTX can potentially treat a variety of medical ailments, including heroin and cocaine withdrawal symptoms, spinal cord injuries, brain trauma, and some kinds of tumors. Here, we (i) describe the perplexing evolution and ecology of tetrodotoxin, (ii) review its mechanisms and modes of action, and (iii) offer an overview of the numerous ways it may be applied as a therapeutic. There is much to be explored in these three areas, and we offer ideas for future research that combine evolutionary biology with therapeutics. The TTX system holds great promise as a therapeutic and understanding the origin and chemical ecology of TTX as a poison will only improve its general benefit to humanity.