COVID-19 pandemic and methanol poisoning outbreak in Iranian children and adolescents: A data linkage study.

BACKGROUND: During the first wave of COVID-19, many Iranians were poisoned by ingesting hand sanitizers and/or alcoholic beverages to avoid viral infection. To assess whether the COVID-19 pandemic resulted in an increased prevalence of accidental hand sanitizer/alcoholic beverage exposure in children and adolescents, we compared pediatric hospitalization rates during COVID-19 and the previous year. For poisoning admissions during COVID-19, we also evaluated the cause by age and clinical outcomes. METHODS: This retrospective data linkage study evaluated data from the Legal Medicine Organization (reporting mortalities) and hospitalization data from nine toxicology referral centers for alcohol-poisoned patients (age 0 to 18 years) for the study period (February 23 to June 22, 2020) and the pre-COVID-19 reference period (same dates in 2019). RESULTS: Hospitalization rates due to ethanol and methanol exposure were significantly higher in 2020 (n = 375) than 2019 (n = 202; OR [95% CI] 1.9 [1.6, 2.2], p < 0.001). During COVID-19, in patients ≤15 years, the odds of intoxication from hand sanitizers were significantly higher than from alcoholic beverages, while in 15- to 18-year-olds, alcoholic beverage exposure was 6.7 times more common (95% CI 2.8, 16.1, p < 0.001). Of 375 children/adolescents hospitalized for alcoholic beverage and hand sanitizer exposure in 2020, six did not survive. The odds of fatal outcome were seven times higher in 15- to 18-year-olds (OR (95% CI) 7.0 (2.4, 20.1); p < 0.001). CONCLUSION: The Iranian methanol poisoning outbreak during the first wave of COVID-19 was associated with significantly increased hospitalization rates among children and adolescents-including at least six pediatric in-hospital deaths from poisoning. Public awareness needs to be raised of the risks associated with ingesting alcoholic hand sanitizers.

Non -fatal overdose among people who inject drugs in Tehran, Iran.

BACKGROUND: With increasing frequencies of non-fatal overdose in people who inject drugs (PWID), it is essential to improve our knowledge about associated risk factors for overdose to inform overdose prevention and assistance programs. The aim of present study was to determine the prevalence of non-fatal overdose and the associated risk factors among PWID in Tehran, Iran. METHODS: Snowball sampling was used to collect data from 465 participants in Tehran using a cross-sectional survey. Consenting participants who reported drug injecting in the past month and were able to speak and comprehend Farsi enough to respond to survey questions were interviewed. The endpoint of interest was non-fatal overdose in the previous 6 months, or answering "Yes" to the question: "In the last six months, have you ever overdosed by accident? (at least once)". We used STATA v. 14 for this analysis. Statistical significance was defined as p < 0.05 for all analyses. RESULTS: Of 465 PWIDs who participated in this study, all were male, and about half had less than a high school education. The prevalence of self-reported non-fatal overdose in the past 6 months was 38% (CI95%: 34, 43%). Our findings indicate that characteristics and behaviors that were associated with an increased risk of experiencing an overdose in the past 6 months were drug use initiation under 22 years (AOR =2.2, P < 0.05), using methamphetamine (AOR =2.8, P < 0.05), and using multiple drugs at the same time (AOR =2.1, P < 0.05). Also, more recent initiates to injecting (< 2 years) had an increased risk of experiencing an overdose in the past 6 months. The odds of experiencing a non-fatal overdose among PWIDs who regularly attended NSP were 0.6 times less than for those who did not attend regularly (OR = 0.6,95% CI: 0.2-0.9). CONCLUSION: Methamphetamine and alcohol use were the most significant association for non-fatal overdose among PWIDs. Our results indicate that intervention and prevention initiatives seeking to reduce overdoses among PWIDs should not only be focused on the primary drug used but also the use of alcohol and poly-drug use.

Evaluation of methanol content of illegal beverages using GC and an easier modified Chromotropic acid method; a cross sectional study.

BACKGROUND: Methanol is highly toxic to human beings and naturally exists in some beverages. Having access to an easy and cheap method for its determination is of great importance to increase the safety of use of these beverages. Our main aim is to evaluate methanol concentration of some alcoholic beverages in Iran black market and compare it with the European and US standards. Also, we evaluated the efficacy of a newly designed and produced chemical kit in determining the risk of methanol toxicity by drinking of such samples compared to gas chromatography method. METHODS: Methanol content of suspected alcoholic beverages referred to forensic toxicology laboratory, Guilan province, Iran was measured using gas chromatography and a recently designed kit based on modified colorimetric chromotropic acid method. RESULTS: Of 1221 samples, 145 (11.9%) had no ethanol content, while in three samples (0.25%), methanol was high enough (700,000; 870,000; 920,000 mg/L) to cause severe methanol toxicity. Median [IQR] ethanol content of the suspected samples was 9% [3.7, 32.75]. Methanol was detected in 128 (10.48%) samples using gas chromatography method and 160 samples (13.1%) with designed kit with 100% sensitivity, 97.07% specificity, and 100% negative-predictive-value. CONCLUSIONS: Alcoholic beverages produced in local black market in Iran are not safe at all. The application of the new method is practical, rapid, easy, and accurate to evaluate the risk of methanol toxicity in suspected alcoholic drinks.

Acute poisoning related to the recreational use of prescription drugs: an observational study from Oslo, Norway.

BACKGROUND: Recreational use of prescription drugs is widespread. We describe acute poisonings related to the recreational use of prescription drugs. METHODS: Retrospective observational study. We retrospectively registered all patients presenting from October 2013 through March 2015 at a primary care emergency outpatient clinic in Oslo, Norway, with an acute poisoning related to recreational drug use. We registered demographic data, toxic agents taken, clinical course and treatment. From this data set we extracted the 819/2218 (36.9%) cases involving one or more prescription drugs. RESULTS: Among the 819 included cases, 190 (23.2%) were female. Median age was 37 years. The drugs most commonly involved were benzodiazepines in 696 (85.0%) cases, methadone in 60 (7.3%), buprenorphine in 53 (6.5%), other opioids in 56 (6.8%), zopiclone/zolpidem in 26 (3.2%), and methylphenidate in 11 (1.3%). Prescription drugs were combined with other toxic agents in 659 (80.5%) cases; heroin in 351 (42.9%), ethanol in 232 (28.3%), amphetamine in 141 (17.2%), cannabis in 70 (8.5%), gamma-hydroxybutyrate (GHB) in 34 (4.2%), cocaine in 29 (3.5%), and other illegal drugs in 46 (5.6%). The patient was given naloxone in 133 (16.2%) cases, sedation in 15 (1.8%), and flumazenil in 3 (0.4%). In 157 (19.2%) cases, the patient was sent on to hospital. CONCLUSIONS: One in three acute poisonings related to recreational drug use involved prescription drugs. Benzodiazepines were by far the most common class of drugs. Prescription drugs had mostly been taken in combination with illegal drugs or ethanol.

Consensus statements on the approach to patients in a methanol poisoning outbreak.

Background: Methanol poisoning is an important cause of mortality and morbidity worldwide. Although it often occurs as smaller sporadic events, epidemic outbreaks are not uncommon due to the illicit manufacture and sale of alcoholic beverages.Objective: We aimed to define methanol poisoning outbreak (MPO), outline an approach to triaging an MPO, and define criteria for prioritizing antidotes, extracorporeal elimination treatments (i.e., dialysis), and indications for transferring patients in the context of an MPO.Methods: We convened a group of experts from across the world to explore geographical, socio-cultural and clinical considerations in the management of an MPO. The experts answered specific open-ended questions based on themes aligned to the goals of this project. This project used a modified Delphi process. The discussion continued until there was condensation of themes.Results: We defined MPO as a sudden increase in the number of cases of methanol poisoning during a short period of time above what is normally expected in the population in that specific geographic area. Prompt initiation of an antidote is necessary in MPOs. Scarce hemodialysis resources require triage to identify patients most likely to benefit from this treatment. The sickest patients should not be transferred unless the time for transfer is very short. Transporting extracorporeal treatment equipment and antidotes may be more efficient.Conclusion: We have developed consensus statements on the response to a methanol poisoning outbreak. These can be used in any country and will be most effective when they are discussed by health authorities and clinicians prior to an outbreak.

The Canadian alcopop tragedy should trigger evidence-informed revisions of federal alcohol regulations.

On 1 March 2018, a 14-year-old girl was found lifeless in a stream behind her high school after having consumed FCKDUP-a beverage containing 11.9% alcohol and sold in 568 mL cans-during her lunch hour. Following her death, the Canadian government took actions at ministerial and parliamentary levels by seeking experts' advice to better regulate highly sweetened alcoholic beverages, otherwise referred to as 'alcopops'. We suggest that the Canadian government uses the work surrounding the alcopop tragedy as an opportunity to make significant amendments and revisions of federal alcohol regulations.

Evaluation of Ethyl Glucuronide and Ethyl Sulfate in Calliphora Vicina as Potential Biomarkers for Ethanol Intake.

Ethyl glucuronide (EtG) and ethyl sulfate (EtS) are specific and sensitive biomarkers for the diagnosis of acute or chronic alcohol abuse. Due to postmortem alcohol production in biological tissues, they have recently been evaluated as potential biomarkers of ethanol ingestion. This in vitro study aimed to evaluate all developmental stages of the fly Calliphora vicina L. (Calliphoridae). Different pig substrates were used during the in vitro experiments to rear C. vicina Experiments were performed to: (i) assess the presence of EtG and EtS in larvae, pupae and insects; (ii) study variability due to the substrates characteristics; (iii) evaluate the possibility of false positives due to external alcohol contamination; and (iv) estimate the potential metabolism of ethanol by the insects. EtS was found in all of the samples where the standard was added to the substrate. Muscle provided the most reliable results. EtS was found in larvae, pupae and puparia. EtG and EtS were found in larvae and pupae collected from the body of an alcoholic found dead in his home. This study showed that maggots, pupae and puparia could be a useful matrix for the evaluation of antemortem alcohol ingestion.

Unintentional alcohol and drug poisoning in association with substance use disorders and mood and anxiety disorders: results from the 2010 Nationwide Inpatient Sample.

OBJECTIVE: To examine unintentional alcohol and drug poisoning in association with substance use disorders (SUDs) and mood and anxiety disorders. METHOD: International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) external-cause-of-injury codes on discharge records of patients ages 12+ years from the 2010 Nationwide Inpatient Sample were examined to identify cases with unintentional alcohol poisoning (E860) and/or drug poisoning (E850-E858). ICD-9-CM diagnosis codes were examined to identify comorbid alcohol dependence, drug dependence, tobacco use disorder, and mood/anxiety disorders. Poisson regression was used to derive risk ratios to assess the associations between these comorbid conditions and alcohol/drug poisoning. RESULTS: Estimated numbers of hospitalisations related to unintentional alcohol and drug poisoning were, respectively, 5623 and 60 423 in men, and 3147 and 68 568 in women. For both sexes, the proportion with SUDs or mood/anxiety disorders was significantly higher among inpatients with alcohol and drug poisoning than among all inpatients. Estimated risk ratios indicated strong relationships of SUDs and mood/ anxiety disorders with unintentional poisoning from alcohol and drugs. The strongest association was between alcohol dependence and alcohol poisoning for both sexes. Significant associations also existed between drug dependence and drug poisoning, and mood/anxiety disorders and poisoning from alcohol and drugs. CONCLUSIONS: SUDs and mood/anxiety disorders are key risk factors for unintentional poisoning by alcohol and drugs among inpatients in the USA. Effective treatments of these disorders should be targeted as poisoning prevention efforts. Future studies are needed to clarify a potential bias in the data due to differential inpatient mental condition screening practices.

Acute alcohol intoxication in a 15-day-old neonate.

We describe a 15-day-old newborn girl who was fed with formula milk that was accidentally diluted with sake (Japanese wine prepared from fermented rice). The clinical features were flushed skin, tachycardia and low blood pressure indicating circulatory failure, somnolence and metabolic acidosis without hypoglycemia. The serum ethanol concentration was 43.0 mg/dL at 3 h after intake. The patient recovered under intravenous fluid replacement without complications. Follow-up examinations at 1, 2, 3, 6 and 12 months confirmed normal psychomotor development.

An analysis of energy-drink toxicity in the National Poison Data System.

CONTEXT: Small studies have associated energy drinks-beverages that typically contain high concentrations of caffeine and other stimulants-with serious adverse health events. OBJECTIVE: To assess the incidence and outcomes of toxic exposures to caffeine-containing energy drinks, including caffeinated alcoholic energy drinks, and to evaluate the effect of regulatory actions and educational initiatives on the rates of energy drink exposures. METHODS: We analyzed all unique cases of energy drink exposures reported to the US National Poison Data System (NPDS) between October 1, 2010 and September 30, 2011. We analyzed only exposures to caffeine-containing energy drinks consumed as a single product ingestion and categorized them as caffeine-containing non-alcoholic, alcoholic, or "unknown" for those with unknown formulations. Non-alcoholic energy drinks were further classified as those containing caffeine from a single source and those containing multiple stimulant additives, such as guarana or yerba mate. The data were analyzed for the demographics and outcomes of exposures (unknown data were not included in the denominator for percentages). The rates of change of energy drink-related calls to poison centers were analyzed before and after major regulatory events. RESULTS: Of 2.3 million calls to the NPDS, 4854 (0.2%) were energy drink-related. The 3192 (65.8%) cases involving energy drinks with unknown additives were excluded. Of 1480 non-alcoholic energy drink cases, 50.7% were children < 6 years old; 76.7% were unintentional; and 60.8% were males. The incidence of moderate to major adverse effects of energy drink-related toxicity was 15.2% and 39.3% for non-alcoholic and alcoholic energy drinks, respectively. Major adverse effects consisted of three cases of seizure, two of non-ventricular dysrhythmia, one ventricular dysrhythmia, and one tachypnea. Of the 182 caffeinated alcoholic energy drink cases, 68.2% were < 20 years old; 76.7% were referred to a health care facility. Educational and legislative initiatives to enhance understanding of the health consequences of energy drink consumption were significantly associated with a decreased rate of energy drink-related cases (p = 0.036). CONCLUSIONS: About half the cases of energy drink-related toxicity involved unintentional exposures by children < 6 years old. Educational campaigns and legal restrictions on the sale of energy drinks were associated with decreasing calls to poison centers for energy drink toxicity and are encouraged.

Methanol poisoning among travellers to Indonesia.

BACKGROUND: Common Travel Medicine sources generally do not provide information on the risk of methanol poisoning among travellers who visit Indonesia. The aim of this analysis was to increase knowledge on this topic through reports from bibliographic databases and Internet sources. METHODS: Case reports and studies on methanol poisoning in Indonesia were retrieved through PubMed, Embase and Google Scholar database searching. The Google search was used to retrieve the Web Media articles reporting fatal and non-fatal methanol poisoning in Indonesia, in a timeframe from 01.01.2009 to 03.03.2013. RESULTS: Three case reports of methanol poisoning involving four travellers to Indonesia were found in bibliographic databases. The media sources searching identified 14 articles published online, reporting 22 cases of methanol poisoning among travellers after consumption of local alcohol beverages. The total number of death cases was 18. Some sources report also a large number of cases among the local population. CONCLUSIONS: Methanol poisoning is likely to be an emerging public health problem in Indonesia, with an associated morbidity and mortality among travellers and local people. Some strategies can be implemented to prevent or reduce harm among travellers.

Botulism from drinking prison-made illicit alcohol - Utah 2011.

Foodborne botulism is a rare, potentially fatal paralytic illness caused by eating food contaminated by Clostridium botulinum toxin. It occurs most often as a single case not linked to others by a common food source. As a result of improvements in food canning, when outbreaks do occur, they typically involve fewer than five persons. During October 2-4 2011, eight maximum security inmates at the Utah State Prison in Salt Lake County were diagnosed with foodborne botulism. An investigation by Salt Lake Valley Heath Department, Utah Department of Health, and CDC identified pruno, an illicit alcoholic brew, as the vehicle. The principal ingredients in pruno are fruit, sugar, and water. Many additional ingredients, including root vegetables, are sometimes added, depending on the availability of foods in prison. A baked potato saved from a meal served weeks earlier and added to the pruno was the suspected source of C. botulinum spores. Many of the affected inmates suffered severe morbidity, and some required prolonged hospitalizations. Knowing the link between pruno and botulism might help public health and correctional authorities prevent future outbreaks, respond quickly with appropriate health-care to inmates with acute descending paralysis and/or other symptoms, and reduce associated treatment costs to states.

Alcohol consumption and risk of gastric cancer: a cohort study of men in Kaunas, Lithuania, with up to 30 years follow-up.

BACKGROUND: Gastric cancer is the second most common cause of death from cancer in the world. Epidemiological findings on alcohol use in relation to gastric cancer remain controversial. The aim of this study was to examine the effect of alcohol consumption on the risk of gastric cancer. METHODS: The association between alcohol intake and the risk of gastric cancer was examined in a population-based cohort of 7,150 men in Kaunas, Lithuania, who were enrolled during 1972-1974 or 1976-1980. After up to 30 years of follow-up, 185 gastric cancer cases were identified. Multivariate Cox proportional hazards models were used to estimate hazard ratios (HR) and corresponding 95% confidence intervals (95% CI). The attained age was used as a time-scale. RESULTS: After adjustment for smoking, education level and body mass index, the HR of gastric cancer was 2.00 (95% CI: 1.04-3.82) for the highest alcohol consumption frequency (2-7 times per week) compared with occasional drinking (a few times per year) and 1.90 (95% CI: 1.13-3.18) for ≥ 100.0 g ethanol/week versus 0.1-9.9 g ethanol/week. A stronger effect of alcohol consumption on gastric cancer risk was observed during the second half of the study (1993-2008). In the analysis of gastric cancer risk by alcoholic beverage type, all beverages were included simultaneously in the model. The multivariate HR for men who consumed ≥ 0.5 litre of wine per occasion (compared with those who consumed <0.5 litre) was 2.95 (95% CI: 1.30-6.68). Higher consumption of beer or vodka was not statistically significantly associated with gastric cancer risk. After adjustment for smoking, education level, body mass index and ethanol, we found no excess risk of gastric cancer in association with total acetaldehyde intake. CONCLUSIONS: This study supports a link between alcohol consumption (primarily from ethanol) and the development of gastric cancer in the Lithuanian population. Although an association with heavy wine consumption was observed, the effect of exposure to acetaldehyde on the development of gastric cancer in this cohort was not confirmed. Further research is needed to provide a more detailed evaluation of alcohol drinking and gastric cancer risk.

Toxic cocktail: methanol poisoning in a tourist to Indonesia.

Methanol poisoning has become very uncommon in Australasia with regulations that have reduced its retail availability. This report describes a young tourist who developed sudden onset visual failure and rapid breathing 2 days after ingestion of a complimentary local drink called Arrack when travelling in Indonesia. She presented to a hospital in New Zealand with severe metabolic acidosis and a highly toxic methanol level at 17 mmol/L. The cocktail was consumed at a popular tourist bar but is likely to have been mixed from home-brewed or 'moonshine' alcohol tainted with methanol. The aetiology of methanol poisoning, its optic toxicology and therapeutic measures are discussed, as is the concerning number of methanol poisoning cases among tourists to Indonesia over recent years.

Evaluation and referral for child maltreatment in pediatric poisoning victims.

OBJECTIVE: Although the majority of poisonings in young children are due to exploratory ingestions and might be prevented through improved caregiver supervision, the circumstances that warrant evaluation for suspected maltreatment and referral to Child Protective Services (CPS) are unclear. Therefore the objective of this study was to determine the percentage and characteristics of young poisoning victims who were evaluated for child maltreatment by the hospital team (social work and/or child protection team) and/or referred to CPS. METHODS: Retrospective study of poisoning victims<6 years old seen at an urban children's hospital from 2006 to 2008. Logistic regression was performed to evaluate the associations between the outcomes (evaluation for maltreatment by hospital team and/or referral to CPS) and predictor variables (demographics and circumstances, type and severity of poisoning). RESULTS: Among 928 poisonings, 41% were from household products, 20% from over-the-counter drugs, 7% from prescription narcotics/sedatives, 29% from other prescription drugs, and ≤ 1% each from ethanol, illicit drugs, or other substances. Most children were asymptomatic (69%) or stable (28%); 3% were critically ill. Only 13% were evaluated by the hospital team and 4% were referred to CPS. Demographic characteristics were not associated with referral to CPS. Higher clinical severity was associated with increased referral (p<0.001). Compared to poisonings with over-the-counter drugs, referrals were more likely for poisonings with ethanol and prescription narcotics/sedatives, but not other prescription drugs or household products (p<0.001). All illicit drug poisonings and 44% of ethanol poisonings were referred. The majority of referrals to CPS were for concerns for illicit drugs, poor supervision or multiple forms of maltreatment; 6% were secondary to concerns for intentional poisoning. CONCLUSIONS: Evaluations and referrals to CPS for maltreatment are uncommon in young poisoning victims. Referrals occurred consistently for illicit drugs but not ethanol. Although referrals were more likely for higher severity poisonings, it is unclear if the severity of poisoning is associated with the level of supervisory neglect or a marker of ongoing risk to the child. These findings suggest the need to identify risk factors for ongoing harm and the development of clinical guidelines used to determine which poisoning victims should be referred to Child Protective Services.

Hemodialysis for methyl alcohol poisoning: a single-center experience.

Methanol is a cheap and potent adulterant of illicit liquors. Hemodialysis (HD) is the best method to rapidly remove both toxic acid metabolites and parent alcohols, and it plays a fundamental role in treating severely poisoned patients. This retrospective study was carried out on 91 patients with detectable serum methanol levels who underwent HD. Because toxic alcohol levels were not immediately available, the initial diagnosis and treatment was based on clinical history with evidence of toxic alcohol intake, presence of high anion metabolic acidosis and/or end organ damage. Patients received bicarbonate, ethanol, according to clinical features and blood gases. Patients underwent HD in the setting of known methanol ingestion with high anion gap metabolic acidosis, or evidence of end-organ damage, regardless of methanol level. HD prescription included large surface area dialyzer (≥ 1.5 m²), blood flow rate of 250-350 mL/min and dialysate flow rate of 500 mL/min for 4-6 h. Between 9 and 11 July 2009, 91 males with mean age 40 ± 8.5 years underwent HD, and 13 patients required a second HD session. Patients consumed 100-500 mL illicit liquors, and symptoms appeared six and 60 h later. Clinical features were gastro-intestinal symptoms (83.5%), visual disturbances (60.4%), central nervous system symptoms (59.3%) and dyspnea (43.9%). Before HD, mean pH was 7.11 ± 0.04 (range 6.70- 7.33) and mean bicarbonate levels were 8.5 ± 4.9 mmol/L (range 2-18). Three patients died due to methanol intoxication. Mortality was associated with severe metabolic acidosis (pH ≤ 6.90), ventilator requirement and coma/seizure on admission (P < 0.001). Timely HD, bicarbonate, ethanol and supportive therapy can be life-saving in methanol intoxication.