Deliberate Self-Poisoning with Plants in Southeastern France, a Poison Center 20-Year Report.

INTRODUCTION: In a few regions of the globe, deliberate botanical intoxication may induce significant rates of toxicity and fatality. The objective of this report was to describe plant self-intoxication using the experiences of the southeastern France poison control center (PCC) between 2002 and 2021. RESULTS: During those 20 years, 262 deliberate plants poisonings were reported involving 35 various plants. In most of the cases, poisoning was caused by Nerium oleander (n = 186, 71%), followed by the Datura genus (4.2%), Ricinus communis (3.8%), Taxus baccata (1.9%), Digitalis purpurea (1.2%), Aconitum nape (1.9%), Myristica fragans (1.5%), and Pyracantha coccine (1.2%). Through the 262 plants poisonings, 19 patients among the 186 Nerium oleander poisonings received Digifab as an antidote and 1 patient received physostigmine among the 11 Datura poisonings. Only four deaths were reported for this review, each involving Nerium oleander. DISCUSSION: The first involved species was Nerium oleander (71% of all plants poisonings), then Datura sp and Ricinus communis. It is explained by this native local species' important repartition. Most patients must be admitted to an emergency department for adapted medical care; however, only 41 of them described severe poisonings symptoms. Even fewer needed an antidote, only 20 patients. There is no protocol for the use of a specific treatment, and it might be interesting to develop one for this purpose. MATERIAL AND METHODS: This retrospective review was realized with files managed by the southeastern France PCC based in Marseille from 2002 to 2021. Our department covers the complete French Mediterranean coast, Corsica, and tropical islands (Reunion Island, Mayotte). For every patient, toxicity was evaluated using the Poison Severity Score (PSS).

French Scorpionism (Mainland and Oversea Territories): Narrative Review of Scorpion Species, Scorpion Venom, and Envenoming Management.

Sixty-seven scorpion species have been described in France and its territories, where they have been found to be heterogeneously distributed. Indeed, only one species can be found on Réunion Island, while 38 species exist in French Guiana. The number of stings is also heterogenous, with up to 90 stings per 100,000 inhabitants occurring annually. Scorpion species can frequently be determined through simple visual factors, including species of medical importance (i.e., Buthus, Centruroides and Tityus). Scorpion venom is composed of local enzymes and peptides with a cysteine-stabilized α/ß motif (NaTxs, Ktxs, Calcines), which allow for venom diffusion and the prey's incapacitation, respectively. Harmful scorpion species are limited to Centruroides pococki in the French West Indies, which can induce severe envenoming, and the Tityus obscurus and Tityus silvestris in French Guiana, which can cause fatalities in children and can induce severe envenoming, respectively. Envenomation by one of these scorpions requires hospital monitoring as long as systemic symptoms persist. Typical management includes the use of a lidocaine patch, pain killers, and local antiseptic. In the case of heart failure, the use of dobutamine can improve survival, and pregnant women must consult an obstetrician because of the elevated risk of preterm birth or stillbirth. France does not have scorpion antivenom, as scorpion stings are generally not fatal.

Comorbidities and the right dose: antipsychotics.

INTRODUCTION: The effects of antipsychotic drugs are dose-dependent, which is particularly true for their efficacy, each antipsychotic having a specific dose-response curve. This may justify individualizing doses for these agents. AREAS COVERED: We review the pharmacokinetic profiles of seven oral antipsychotics: haloperidol, risperidone, olanzapine, clozapine, quetiapine, ziprasidone, and aripiprazole. Their main indications are psychotic and affective disorders. They are prescribed in a very large population which may have comorbidities. Hence, we analyze the impact of the latter on the pharmacokinetic profiles of these antipsychotics, focusing on renal and hepatic impairment. Reviews and clinical trials were discussed based on a systematic literature search (PubMed) ranging from 1995 to 2022. EXPERT OPINION: Factors liable to impact antipsychotic dosage are numerous and their subsequent effects often hard to predict, due to multilevel interactions and compensatory phenomena. In clinical practice, physicians must be aware of these potential effects, but base their decisions on monitoring antipsychotic plasma levels.

Unusual Sting by a Nonindigenous Caterpillar in Europe.

On the French island of Corsica, a 57-y-old woman without significant medical history was stung on the left thumb while she was taking care of an ornamental Ficus benjamina plant. Immediately, she felt intense pain in her hand. She saw a strange caterpillar, later identified by the local poison center as Acharia stimulea. The pain in her hand was evaluated as 8 of 10 using the numerical pain rating scale; only a slight erythema was visible on her skin. Symptoms disappeared within 2 h with use of local anti-inflammatory ointment and oral painkillers. Three other caterpillars emerged out of the soil of the potted plant during the following week. This sting by a saddleback caterpillar is exceptional in Corsica. French garden store owners and healthcare professionals should be informed that caterpillars can be imported across the oceans to Europe on different plants.

Relationship Between Scorpion Stings Events and Environmental Conditions in Mainland France.

In the world, the impact of environmental conditions on the number of scorpion events was evaluated in North Africa,Middle East, and the Amazonian region but not in Europe. In mainland France, scorpion species described are Buthus occitanus (Amoreux, 1789), Belisarius xambeui (Simon, 1879) and 4 Euscorpiidae: Euscorpius concinnus (Koch, 1837), Euscorpius italicus (Herbst, 1800), Euscorpius tergestinus (Koch, 1837), and Tetratrichobothrius flavicaudis (De Geer, 1778). We aimed to describe the impact of environmental conduction on the number of scorpion events. For this, a retrospective multi-center study was conducted with data from the French poison control centers files about scorpion events between 1 January 2011 and 31 December 2020. During the study period, 975 incoming calls for scorpion events were recorded and 574 were related to scorpions native to mainland France and Corsica: B. occitanus (n = 86), Euscorpiidae species (n = 222), B. xambeui (n = 1), and undetermined species (n = 265). Cases were mostly reported along the Mediterranean coast, along rivers, and in cities with a trading port. The number of scorpion events was linked to the rivers' water level, rivers' flow, temperature, sunshine, and pluviometry (P < 0.05 for all variables). B. occitanus need warmest and driest environment than Euscorpiidae spp. A link between the severity of the envenoming and climatic condition or seasonality was not demonstrated.

Cannabinoid hyperemesis syndrome in two French emergency departments: a prospective cohort.

Chronic cannabis use can be associated with uncontrollable vomiting and abdominal pain. Diagnostic criteria for cannabinoid hyperemesis syndrome (CHS) were defined in 2012 by Simonetto et al. The objectives of this study were to describe the prevalence of CHS, the patients' epidemiological characteristics, and to show the difficulties encountered in caring for these patients in emergency departments, the extent of health care and an unsuitable follow-up in general practices. A prospective cohort of patients with CHS was recruited among a target population of patients leaving the adult emergency services of the Marseille hospitals Nord and La Timone between October 2017 and July 2018, with abdominal pain syndrome of unidentified etiology. Inclusion criteria for the CHS cohort were chronic cannabis use associated with nausea and vomiting. There were 48 patients included in the CHS cohort who took cannabis daily, in a target population of 2 848 patients (i.e. 1.6%). A hot shower was the most effective symptomatic treatment in 54.2% of cases. Patients suffering from CHS spent significantly more hours in emergency departments (11 vs. 6.5), and, on average, visits were more frequent (4.9 vs. 3). 20.3% of them were hospitalized to continue pain medication. Once out of hospital, follow-up was limited, and weaning off cannabis, the only etiological treatment, was difficult to set up. Informing patients about CHS is essential, and a hot shower could be systematically proposed, thus limiting an unnecessary extent of health care. CHS is genuine, medical staff should be made aware of it in occupational training, and it should be seriously considered in health policies.

Hypervitaminosis A Following the Ingestion of Fish Liver: Report on 3 Cases from the Poison Control Center in Marseille.

In European countries, vitamin A toxicity is most often the result of an excessive intake of vitamin supplements and rarely the consequence of the ingestion of a large carnivorous fish liver. We report 3 cases of vitamin A poisoning after fish liver ingestion in mainland and overseas France. The patients were a 12-y-old girl, a 36-y-old pregnant woman, and a 62-y-old man. They experienced headache, nausea, emesis, and desquamation. Laboratory examination showed a high serum retinol level in the girl. The woman's pregnancy progressed to a miscarriage. This case series shows that this kind of poisoning is not restricted to the polar regions. In patients presenting with flushing combined with signs of intracranial hypertension, accurate questioning of the patient's diet is crucial to avoid misdiagnosis and unnecessary examinations. Pregnant women or women of child-bearing age should be informed of the risk to pregnancy in the case of excessive fish liver ingestion.

Toxicological considerations in the prescription of baclofen for the treatment of substance use disorders.

Introduction: For many years, applications for baclofen have widened in the treatment of substance abuse disorder (SUD), mainly alcohol use disorder, with a growing rate of off-label prescriptions in Europe. Clinical effects seem to be both a decrease of craving and anxiety, leading to a decrease of drug or alcohol consumption. We described baclofen poisoning circumstances, therapeutic options and outcomes when used in substance use disorders.Areas covered: This review summarizes the toxicological considerations where baclofen was prescribed in humans for substance use or abuse disorder in randomized clinical trials, case series, case reports and observational studies between 1990 and 2020 according to the Preferred Reporting Items for Systemic reviews and Meta-Analysis.Expert opinion: The most frequent cause of severe intoxication is self-poisoning. A dose above 180 mg are expected to cause severe toxicity and death. The treatment is only symptomatic as no antidote is available. Off-label prescription remains unsafe because the optimal dose is not known and varies greatly between patients. As SUD are frequently associated with psychiatric disorders and such patients may have suicidal thoughts, the risk of self-poisoning is high. Potential co-ingestants should also be considered, especially CNS depressants, and they need to be closely monitored.

Methadone poisonings: a seven-year retrospective study of the French poison center network focusing on suicide attempts vs. misuses.

Methadone has been prescribed in France as opioid substitution therapy as a syrup formulation since 1995 and as capsules since 2008. Following two publications showing on a national scale the high risk of methadone poisoning in children and the lack of difference in poisoning severity between both methadone formulations, French health authorities chose to benefit from the experience acquired by the network of French poison centres concerning poisoning by this substitution medication. The aim of this study was to identify and compare the main circumstances of methadone exposure collected by a poison centre on a national scale over a period of 7 years. Retrospective descriptive study of cases of methadone exposure was compiled by the network of French poison centres between 15 October 2010 and 15 October 2017. Analysis of 1415 files revealed two major circumstances: 47% misuse and 41% suicide attempts. Severity scores evaluated according to the PSS were higher for misuse than for suicidal behaviour, despite the supposed ingested dose being statistically higher in the latter. The results also confirmed the lack of significant difference in methadone exposure between both of the formulations (syrup and capsules). This series of methadone exposure on a national scale is one of the largest compiled series in international medical literature. On the one hand, it highlights the severity of methadone poisoning (in suicidal behaviour and even more so in misuse behaviour), and on the other hand, it confirms that the capsule formulation does not seem to represent a higher risk than the syrup formulation.

Adverse consequences of low-dose methotrexate medication errors: data from French poison control and pharmacovigilance centers.

OBJECTIVE: The objectives of this study are to carefully describe the context of methotrexate medication errors, to details medical consequences and management approaches, and to determine the rate of fatal outcome. METHODS: Data on methotrexate medication errors were obtained from the French network of poison control and pharmacovigilance centres, which collected and documented reported drug-induced adverse effects. Cases were included if the intake was more than 2-fold the intended weekly dose or a weekly cumulative dose ≥ 30 mg and a follow-up of at least 4 days after the last dose. Data were analysed for demographics, treatment indication, prescribed dose, drug interactions, clinical complications and medical outcomes. RESULTS: Seventy four patients were included. The causes of methotrexate errors resulted from an erroneous prescription renewal (23.3%), incomprehensiveness of the weekly schedule by patients or at-home caregivers (56.2%) and administration of a wrong dose by a health care professional (20.5%). Of the 70 patients who took methotrexate daily, the mean daily dose received over the whole duration of the error was 9.6 ± 4.1 mg (range 2.5-22.5) with a mean duration of the error of 11.7 ± 12.2 days (range 2 to 90). Thirteen (18%) patients remained asymptomatic and 61 (82%) developed complications of which 46 (62.2%) were severe. Nine (14.8%) patients died within 11 to 45 days after the first dosing error. Compared to patients with no or mild symptoms, those with severe symptoms were more likely to be older (75.6 ± 10.8 vs. 69.5 ± 12.9 years) and to be exposed to a higher cumulative dose (94.8 ± 46.2 vs. 68.0 ± 45.7 mg). CONCLUSIONS: This study confirms that dosing errors with methotrexate can be lethal and persisted despite several warnings from drug agencies. Further measures are awaited from the European Medicine Agency.

Risperidone medication errors in children: an analysis of French poison centres data.

OBJECTIVES: To describe clinical consequences of risperidone medication errors in children of less than 13 years and to estimate a clinically relevant toxic dose. METHODS: All cases of risperidone medication errors managed by French Poison Centres from 2001 to 2012 were analyzed. Inclusion criteria were a delay of at least 2 hours between ingestion and request to the FPC in asymptomatic children, an ingested dose above two-fold the maximal daily dose for children above 5 years or any symptomatic patient at the time of first contact. RESULTS: One hundred and sixty cases met our criteria. Median age was 8 years (range 0.9-12) and 28.1% were aged 5 years or less. Causes of the error were an incorrect dose in treated children (84.2%) or a dose given to a wrong child (15.8%). The median ingested dose was 0.1 mg/kg or 3.3-fold the maximum recommended dose. Overall, 59 children had no symptoms, 95 experienced minor symptoms and six moderate symptoms. Somnolence/sedation was the most common (73.3%). Of the 17 children who developed extrapyramidal disorders, all had minor or moderate symptoms and only five required a symptomatic treatment. CONCLUSIONS: Risperidone medication errors in children cause minimal effects. Somnolence and mild to moderate extrapyramidal reactions were the main features of toxicity, and significant cardiac or other neurological features were not observed. No case with severe toxicity was noted. At home surveillance can be proposed for children exposed to a dose ≤0.15 mg/kg.

Misuse of Trihexyphenidyl (Artane) on Réunion Island.

BACKGROUND: Trihexyphenidyl (THP) is an anticholinergic drug misused to procure hallucination, sedation, and anxiolysis. The aim of this cohort was to show and describe, within a public health risk management policy, the risks of a long-standing but relatively unknown addiction: THP addiction. METHODS: On Réunion island, a cohort with systematic data collection has been set up by addictologists working in the Centres for Addiction Prevention and Treatment, in the university hospital, and in general practices who have active lists of patients misusing THP. Data collection included socioeconomic data and clinical data concerning addiction. RESULTS: This cohort included 69 patients during November 2016. The average age of the patients was 36 years; 97% were men; 93% had living accommodation but only 32 % were employed. In this cohort drug administration was exclusively oral. The most common reasons for use were anxiolytic (46%), stimulation (26%), and sedation (10%), the main effects described were dyskinesia and behavioral disorders. Over half (61%) of the patients reported a coaddiction, mainly to benzodiazepines, cannabis, tobacco, alcohol, and buprenorphine. CONCLUSIONS: This cohort describing the clinical characteristics of 69 patients is the largest cohort studied for THP addiction. Patients from the Centres for Addiction Prevention and Treatment were the youngest and most recently addicted, whereas general practice patients had been addicted for longer and were more socially integrated. This clinical description of THP addiction therefore enables us to identify the patients who are the most at risk, to set up an adapted care protocol.

Transmission of force to the hyoid bone during manual strangulation: Simulation using finite element numerical models.

INTRODUCTION: Strangulation is a medicolegal form of mechanical asphyxia, and can be difficult to identify if cutaneous damage to the neck is limited. We began by creating a numerical model of a hyoid bone with adjustable anthropometric parameters and then subjected our model to compression simulating a precision grip on the neck from the front. MATERIALS AND METHODS: We selected six bones from the 77 hyoid bones contained in the database we created during a previous study led by our laboratory, in which we demonstrated the sexual dimorphism of this bone and identified the minimal force required for fracture. The anthropometric characteristics of these six bones (angle, length and width) corresponded to those of the 10th, 50th and 90th percentiles from cluster 1 (male individuals) and cluster 2 (female individuals), respectively. After enhancing, developing and meshing the selected 3D models, we analysed and reproduced simulation conditions that were as close as possible to the in vivo conditions of neck strangulation from the front (area of pressure on the bone, tissue environment, and biological variability of this bone). RESULTS: We modelled the six numerical hyoid bone models using the finite element method. For all models, the simulation of mechanical pressure applied to simulate anterior strangulation resulted in fractures. The forces required to produce these fractures matched the results obtained in the experimental testing of dissected hyoid bones. CONCLUSION: Six finite element numerical models were created, covering the anthropometric morphological variability of the hyoid bone. These six models enabled numerical simulation of the in vivo behaviour of a hyoid bone subjected to one-handed strangulation.