Trends in Nonfatal Overdose Rates Due to Alcohol and Prescription and Illegal Substances in Colombia, 2010‒2021.

Objectives. To examine drug overdoses in Colombia by type of substance, sex, age, and intent using data from a health surveillance system from 2010 to 2021. Methods. We characterized data by year, type of substance, and sociodemographic variables. We calculated age-adjusted overdose rates by substance type, sex, age groups, and intent. We used Poisson regression models to examine trend differences across sex and age groups. Results. Age-adjusted rates of drug overdoses increased from 8.51 to 40.52 per 100 000 during 2010 to 2021. Men, compared with women, had higher overdose rates for every substance, except for opioids and psychotropics. Drug overdose rates involving cannabis and stimulants increased steadily until 2017 but decreased afterward. Overdose rates involving psychotropic medication increased greatly during 2018 to 2021, mainly because of intentional overdoses in young women. Conclusions. Overdoses involving illegal drugs decreased in recent years in Colombia; however, the continuous increase in intentional psychotropic overdose rates highlights the need for prevention efforts to curb this trend. Health surveillance systems are an important tool that can guide overdose prevention efforts in countries with limited data resources. (Am J Public Health. 2024;114(11):1252-1260. https://doi.org/10.2105/AJPH.2024.307786).

Preventing Pediatric Opioid Poisoning: Unusual Sources and Scenarios.

This retrospective study analyzed 230 pediatric opioid exposures from a statewide poison control center over a 5-year period. Most exposures involved pharmaceutical opioids and children below 2-years-old. Narrative details were reviewed to identify uncommon sources of opioids involved in poisoning and highlight the need for tailored prevention strategies and guidance.

Ethnic-racial disparities in poisoning cases: analysis of drugs of abuse, medicines and pesticides in Brazil.

In Brazil, ethnic-racial inequalities exist in all fields, obstructing access to goods, services, and opportunities, including healthcare services. However, there are no apparent studies that assess, at a national level, ethnic-racial disparities in poisoning cases, emphasizing skin color as a determining factor. The study aimed to examine the relationship between race/ethnicity and general poisoning cases, by medications, pesticides, and drug of abuse in Brazilian states. Poisoning cases data were extracted for the years 2017, 2018, and 2019. Notification data for general poisoning cases and toxic agents were collected: medications, pesticides, and drugs of abuse. Data were categorized between whites and non-whites (blacks, browns, and indigenous) and without information on skin color/ethnicity. Rates of poisonings amongst ethnic-racial groups and cases of not declared skin color as well as relative risk (RR) of poisoning among non-whites were calculated. All states in the North, Northeast (states with the worst Human Development Index), Midwest, and 2 states in the Southeast exhibited higher rates of poisoning cases per 100,000 inhabitants among non-whites. The RR values for nonwhite individuals were higher in the North and Northeast regions for all types of poisonings. The type of poisoning cases that presented the highest RR for non-whites over the 3 years was drugs of abuse (2-2.44), when compared to other types of poisonings from pesticides (2-2.33) and medications (1.5-1.91). The spatial distribution of poisoning cases rates and RR of nonwhite population support public policies to reduce socioeconomic and environmental inequalities.

Is tetrodotoxin intoxication the cause of "zombi voice" in Haiti?

OBJECTIVE: Zombification, a magical and religious process in Haiti, has been scientifically studied and remains relevant. Originating from the convergence of African, Caribbean, and Christian rites, it involves a comatose trance, transforming individuals into living dead through Voodoo practices. Haitian zombies consistently exhibit a preserved expression marked by a nasal voice, a result of nasalization-using nasal cavities as resonators during phonation. The aim of this study was to ascertain the mechanisms through which zombification could impact the voices of the subjects. METHODS: A comprehensive investigation was conducted using both primary and secondary sources. Primary sources involved direct or reported testimonies of individuals undergoing zombification, with audio or video recordings available from the collections of the Laboratory of Anthropology, Archaeology, and Biology (UVSQ/Paris-Saclay University), as well as on the internet. Secondary sources encompassed the entirety of existing literature regarding zombification in Haiti on one hand, alterations in the voices of subjects when mentioned on the other hand, and toxicological hypotheses or evidence available on PubMed/Medline and Google Scholar. RESULTS: Few post-zombification observations exist, but 20th-century studies clarified the physio pathological process, confirming its reality. Wade Davis demonstrated in 1983 that zombification results from poisoning, with effects ranging from reversible to fatal, implicating substances like tetrodotoxin and datura. Nasalization can be natural or pathological, affecting various phonemes. No mutilating acts or surgery have been reported related to Haitian zombification. CONCLUSION: The pharmacological characteristics of tetrodotoxin, coupled with testimonials, present a medical hypothesis elucidating the biological mechanism underlying nasalization in this context. Given that tetrodotoxin induces flaccid paralysis as a neurotropic poison, its neurological impact could account for soft palate paralysis or spasms. Additionally, the severe hypotension induced by tetrodotoxin may elucidate oral and pharyngeal necrosis.

[Sargassum seaweed assaults the French West Indies]. / Algues sargasses à l'assaut des Antilles.

SARGASSUM SEAWEED AS SAULTS THE FRENCH WEST INDIES. Since 2011, Martinique and the islands of Guadeloupe have been affected by repeated groundings, culminating in an exceptional wave in 2018. While the sargassum ( Sargassum natans and S. fluitans ) involved in these phenomena are neither toxic nor urticating, indirect toxicity linked to the presence of microorganisms and heavy metals (arsenic, mercury, etc.) in sargassum clusters has been described. Similarly, after a 24 to 48 hours stay on the shore, sargassum algae enter a putrefaction cycle responsible to produce hydrogen sulfide (H2S) and ammonia (NH3). The acute toxicity of these gases is well known. However, very few data are available on the clinical effects of prolonged exposure to low doses of H2S and NH3. Our team has recently described the syndromic features of chronic exposure, supposing for deleterious effects on the cardiovascular, respiratory and neurological systems.

ALGUES SARGASSES À L'ASSAUT DES ANTILLES. Depuis 2011, la Martinique et les îles de la Guadeloupe sont touchées par des échouements à répétition d'algues sargasses qui ont culminé avec une vague exceptionnelle en 2018. Si les sargasses (Sargassum natans et S. fluitans) impliquées dans ces phénomènes ne sont ni toxiques ni urticantes, une toxicité indirecte liée à la présence de micro-organismes et de métaux lourds (arsenic, mercure…) dans les amas de sargasses est décrite. De même, après un séjour de vingt-quatre à quarante-huit heures sur le littoral, les algues sargasses entrent dans un cycle de putréfaction responsable de la production d'hydrogène sulfuré (H2S) et d'ammoniac (NH3). La toxicité aiguë de ces gaz est bien connue. Il existe en revanche très peu de données disponibles sur les effets cliniques d'une exposition prolongée à de faibles doses d'H2S ou NH3. Notre équipe a récemment décrit le tableau syndromique de l'exposition chronique et suppose des effets délétères sur le système cardiovasculaire, respiratoire et neurologique.

The link between pesticide exposure and suicide in agricultural workers: a systematic review.

INTRODUCTION: The aim of this study was to conduct a systematic literature review to find the association between pesticide exposure and the incidence of suicide in agricultural workers, focusing on analyzing the profile of agricultural workers, the countries with the highest number of publications and, especially, the link between occupational exposure to pesticides, the degradation of mental health and suicide among agricultural workers. METHODS: A systematic literature review was conducted following the PRISMA protocol using Scopus, Web of Science, and PubMed databases, where 33 articles were screened to compose the final portfolio. RESULTS: There is a strong link between pesticide exposure and suicide in agricultural workers. Smoking, alcohol consumption, exposure time, and marital status influence the decision to die by suicide. Brazil and the US lead the ranking in publications, demonstrating that it is not a problem only for developing countries. Organophosphates are the main pesticides used, and they degrade an enzyme crucial for the nervous system, which can result in mental disorders and consequent suicide in agricultural workers. CONCLUSION: There is a need for stricter norms for the commercialization and use of pesticides. There is also a need for providing training to agricultural workers on the application and storage of pesticides, and to communicate about the compounds and the consequences of pesticides to mental health.

Trends in drug overdose deaths in Mexico (1999-2019). A national descriptive analysis and interstate comparison.

BACKGROUND: We assess trends in overdose mortality rates in Mexico from 1999 to 2019 and identify the states with the highest overdose mortality rates over time. METHODS: The analysis using mortality statistics examined deaths related to drug use. We estimated general overdose mortality rates at the national and state levels and calculated specific mortality rates associated with opioid and stimulant use using central rate estimation. We used joinpoint regression to analyse national and state-specific trends in overdose mortality from 1999 to 2019. FINDINGS: Nationally, the general overdose mortality rate increased annually by 10.49 % (p < 0.01, CI=11.4-18.9) from 2015 to 2019. The northern states of Baja California and Chihuahua were the states with the higher annual increases (18.6 %, p < 0.01, CI=4.2-29.6; and 15.6 %, p < 0.01, CI=12.9-19.7, respectively). By substance type, the national opioid-related mortality rate increased by 29.82 % per year from 2014 to 2019 (p < 0.01; CI=20.1-40.3), compared with an annual decrease of 11.43 % in the previous period (2005-2014) (p < 0.01; CI=-14.7- 8.0). Baja California was the state with the highest rise in opioid-related mortality from 2013 to 2019, with an annual increase of 15.84 % (p < 0.01; CI=1.4-32.3). Stimulant-related mortality increased by 21.79 % per year since 2013 (p < 0.01; CI=16.9-26.9), but it was not possible to calculate state-level trends. CONCLUSIONS: Drug-related mortality rates have increased in Mexico since 2015, particularly in the northern states of Baja California, Chihuahua, Sonora and Sinaloa. Improving harm reduction programmes and local surveillance of fatal and non-fatal overdoses is essential to address the silent escalation of overdose mortality.

Long-term disability after cerebral ischemic stroke following a Bothrops atrox snakebite in the Brazilian Amazon.

Bothrops atrox envenomations in the Brazilian Amazon are responsible for a number of local and systemic effects. Among these, stroke presents the worst prognosis for the patient since it may evolve into disabilities and/or premature death. This complication is caused by coagulation disorders and generates hemorrhagic and thrombotic conditions. This study presents a case report of a 54-year-old female patient who presented extensive cerebral ischemia after a B. atrox envenomation that occurred in the state of Amazonas, Brazil. The patient was hospitalized for 102 days, which included a stay in the intensive care unit. Clinical and laboratory findings indicated a thrombogenic coagulopathy. On discharge, the patient had no verbal response, partial motor response, and right hemiplegia. The assessment carried out four years after discharge evidenced incapacitation, global aphasia and bilateral lower and upper limbs showed hypotrophy with a global decrease in strength. Ischemic stroke is a possible complication of B. atrox snakebites even after antivenom treatment, with the potential to cause debilitating long-term consequences.

[Liver transplantation as treatment for acetaminophen poisoning]. / Trasplante hepático como tratamiento de intoxicación por paracetamol.

Acetaminophen is a commonly used analgesic and antipyretic drug, which has experienced an increase in its consumption in recent years in our environment. There has also been an increase in the number of accidental and intentional overdoses that were treated by the health system. Its toxicity is dose-dependent and can cause fulminant liver failure, becoming one of the main reasons for liver transplantation in English-speaking countries. The case of a 28-year-old woman with a history of major depression and five previous suicide attempts, who deliberately ingested a significant amount of paracetamol tablets, is here presented. She developed fulminant liver failure and metabolic acidosis, for which she underwent an emergency liver transplant due to the severity of her condition, from which she evolved favorably. The decision to perform a liver transplant in serious cases like this and under a condition of severe psychiatric vulnerability is challenging and must be carefully considered. This particular case illustrates the importance of multidisciplinary care including psychiatric evaluation in patients with acetaminophen poisoning.

El paracetamol es una droga analgésica y antipirética comúnmente utilizada, que ha experimentado un aumento en su consumo en los últimos años en nuestro medio. También se ha observado un incremento en el número de sobredosis accidentales e intencionales que fueron atendidas por el sistema de salud. Su toxicidad es dosis dependiente y puede causar falla hepática fulminante, convirtiéndose en una de las principales razones de trasplante hepático en países angloparlantes. Se presenta el caso de una mujer de 28 años con antecedentes de depresión mayor y cinco intentos de suicidio previos, quien ingirió deliberadamente una cantidad significativa de comprimidos de paracetamol. Desarrolló una falla hepática fulminante y acidosis metabólica, por lo que fue sometida a un trasplante hepático de emergencia debido a la gravedad de su condición evolucionando favorablemente. La decisión de realizar un trasplante hepático en casos graves como este y bajo una condición de vulnerabilidad psiquiátrica grave, es un desafío y debe considerarse cuidadosamente. Este caso en particular ilustra la importancia de la atención multidisciplinaria incluyendo la evaluación psiquiátrica en pacientes con intoxicación por paracetamol.

FACTORS ASSOCIATED WITH A HIGHER NUMBER OF ESOPHAGEAL DILATIONS IN CHILDREN WITH A HISTORY OF ALKALINE INGESTION.

BACKGROUND: Children who experience alkaline injury are at risk for the development of esophageal strictures and the need for esophageal dilations. OBJECTIVE: We aimed to assess predictors for a higher number of esophageal dilatations in children following alkali ingestion. METHODS: Single-center retrospective cohort study including children who underwent esophagogastroduodenoscopy (EGD) after alkali ingestion. Possible predictive factors for the need for esophageal dilatations were evaluated. RESULTS: A total of 34 patients were included, and 19 were female (55.9%). The median age at the time of the accidents was 20.6 months (IQR 15-30.7). All alkali ingestions were accidental, in all cases involving liquid products, and most (24/34; 70%) occurred at the child's home. Homemade liquid soap was the agent in half of the cases. The most frequently reported symptom at presentation was vomiting (22/34, 64.7%). The median follow-up time was 3.2 years (IQR 1.1-7.4). On follow-up, the median number of esophageal dilatations required for these patients was 12.5 (IQR 0-34). Among demographic factors, male gender (P=0.04), ingestion of homemade products (P<0.01), and accidents happening outside of the household environment (P=0.02) were associated with a greater number of esophageal dilations on follow-up. An endoscopic classification Zargar of 2B or higher (P=0.03), the presence of stricture at the time of the second EGD (P=0.01), and gastroesophageal reflux disease (GERD) as a late complication (P=0.01) were also associated with a greater number of esophageal dilations on long term follow-up. CONCLUSION: Beyond the endoscopic classification severity - a well-known risk factor for the strictures after alkali ingestions, we found that male gender, accidents with homemade products, and accidents occurring outside the household environment were significantly associated with a greater number of esophageal dilatations in the long-term follow-up of children following alkali ingestion.

A hospital management algorithm for acute poisoning by Paraquat® in a pediatric population, a series of cases / Algoritmo de manejo hospitalario para la intoxicación aguda por Paraquat® en población pediátrica, serie de casos.

Paraquat®, or N,N'-dimethyl-4,4'-bipyridinium dichloride, is a bipyridyl compound used as a non-selective herbicide and desiccant that can cause acute poisoning through all routes of exposure. There is no known antidote, and the available treatments are based on avoiding its absorption and timely removing it, in adults and children. We describe a case series of 14 pediatric patients from the department of Cauca, Colombia, with acute intoxication after oral intake of paraquat. Patients were referred to a medium-high complexity hospital in southwestern Colombia and treated according to an institutional protocol for acute paraquat poisoning. Acute paraquat poisoning after oral ingestion is associated with a high mortality rate, even with timely medical attention, as the compound has no known antidote and quickly reaches systemic concentrations for fulminant poisoning. Based on the available literature, our center has proposed a clinical protocol including early standard management, immunosuppressive and antioxidant treatments, and systemic removal techniques. This protocol suggests an adequate approach to acute paraquat poisoning in the pediatric population.

El dicloruro de 1,1'-dimetil-4,4'-bipiridilo (Paraquat®) es un compuesto químico de la familia de las piridinas, utilizado como herbicida no selectivo y desecante. Este compuesto puede causar intoxicación aguda por todas las vías de exposición. En el momento, no hay un antídoto conocido y los tratamientos disponibles, incluidos los pediátricos, se basan en contrarrestar su absorción y propiciar su remoción oportuna. Se describe una serie de casos de 14 pacientes pediátricos, procedentes en su mayoría del departamento del Cauca, con intoxicación aguda por ingestión de paraquat. Los pacientes fueron remitidos y atendidos en un hospital de mediana a alta complejidad en el suroccidente colombiano, con un protocolo institucional para el manejo de la intoxicación aguda por el herbicida. La intoxicación aguda con paraquat por vía oral se asocia con una alta tasa de mortalidad, aún con atención médica oportuna, pues fácilmente se alcanzan concentraciones sistémicas para ser fulminante. Basado en la literatura disponible, el Hospital Universitario San José ha propuesto un protocolo clínico ­adecuado para la intoxicación aguda por paraquat en población pediátrica­ que incluye manejo estándar temprano, tratamiento inmunosupresor y antioxidante, y técnicas para su remoción sistémica.

Self-medication cases reported to a poison information center in Brazil from 2014 to 2020.

INTRODUCTION: Self-medication is the use of drugs to treat self-diagnosed illnesses or symptoms, on one's own initiative, without the guidance of a healthcare professional. Poison centers play an important role in understanding the relationship between self-medication and poisoning. The objective of this study is to evaluate the clinical and epidemiological profile of patients exposed to and/or poisoned by different drugs through self-medication. METHODS: This retrospective, cross-sectional, and descriptive study analyzed data from 2014 to 2020, provided by the Toxicological Information and Assistance Center of Santa Catarina, Brazil. Data were selected, tabulated, and analyzed by using descriptive statistics and group comparison with the chi-square test or Fisher's exact test. A P value <0.05 was considered statistically significant. RESULTS: There were 683 cases of self-medication identified. Most patients were female (62.8 percent) and between 20 and 29 years old (26.1 percent). A toxic dose of a substance was administered in only 22.8 percent of the cases, and five deaths were recorded. The most commonly used medications were anxiolytics (18 percent), followed by analgesics and antipyretics (15.4 percent). Paracetamol was the drug used in three of the five cases that resulted in deaths. DISCUSSION: This study demonstrates the prevalence of self-medication among women aged between 20 and 29 years old. Statistical analysis failed to show a relationship between a toxic dose and clinical manifestations. Anxiolytics, analgesics, and antipyretics are the most reported medications probably because healthcare professionals are mostly the ones who contact the center. Analgesics and antipyretics account for more than fifty percent of the deaths caused by self-medication in the present report. Some limitations such as secondary sources are related. CONCLUSION: We highlight the importance of health professionals in promoting the rational use of medicines, as well as poison centers in assisting the population and raising their awareness regarding the issue.

Trends on deaths from acute pesticide poisoning in Mexico, 2000-2021.

OBJETIVE: To provide a comprehensive analysis of mortality trends from acute pesticide poisoning in Mexico from 2000 through 2021. METHODS: The governmental records of deaths from acute pesticide poisoning were used. The age-standardized years of life lost and aged-standardized mortality rates were estimated. Significant changes in trends of annual percentage change were identified using Joinpoint regression. RESULTS: Between 2000 and 2021, mortality was primarily observed in individuals aged 15 to 19 years. Males were the most affected. Self-inflicted pesticide poisoning was the primary registered reason for death. The age-standardized mortality rate from acute pesticide poisoning was reduced from 2012 to 2021 (APC: -4.4; p=0.003). CONCLUSION: This report is the first study about the mortality rate from acute pesticide poisoning in Mexico. The results provided evidence to consider in developing laws to prevent acute pesticide poisoning.

Brazilian Psychiatric Association Consensus for the Management of Acute Intoxication: general management and specific interventions for drugs of abuse.

OBJECTIVES: To present the Brazilian Psychiatric Association's Consensus on the Management of Acute Intoxication. METHODS: A group of experts selected by the Brazilian Psychiatric Association searched for articles on the MEDLINE (by PubMed) and Cochrane databases, limited to human studies and acute intoxication. Working groups reviewed these materials for appropriateness to the topic and the quality of the work. A survey was conducted using the Delphi method to produce a table of agreed recommendations presented at the end of the systematic review. Three survey rounds were held to reach consensus. RESULTS: Support for intoxication should start with Initial Management: Resuscitation/Life Support/Differential Diagnosis. For this, the group proposed the following sequence of assessments: A (airway), B (breathing), C (circulation), D.1 (disability), D.2 (differential diagnosis), D.3 (decontamination), D.4 (drug antidotes), E (enhanced elimination). The group of experts then presented specific interventions for the main drugs of abuse. CONCLUSIONS: Management of intoxication with drugs of abuse is complex and requires systematic protocols. The group suggests adoption of the A-B-C-D-E technique first, with constant investigation. Then, specific conduct and support until remission of intoxication. The literature is still scarce in evidence on the subject. Therefore, this consensus was necessary. We believe that at present this document can help psychiatric, general, and emergency physicians deal with emergency psychiatric episodes due to acute intoxication. This work could stimulate future studies on the topic.

Favorable evolution of severe paraquat poisoning. Treatment with gastric lavage, activated charcoal, cyclophosphamide + corticoids, and conventional daily hemodialysis: case study at the Franck Joly Hospital Center in French Guiana / Évolution favorable d'une intoxication grave au paraquat. Traitement par lavage gastrique, charbon activé, cyclophosphamide + corticoïdes, et hémodialyse conventionnelle quotidienne : étude des cas au centre hospitalier Franck Joly en Guyane française

We report the observations of two patients, having voluntarily ingested lethal doses of paraquat with suicidal intent, with an unfavorable prognostic score. The treatment consisted of gastric lavage, administration of activated charcoal, n-acetylcysteine and cyclophosphamide + methylprednisolone + dexamethasone. The installation of acute renal failure motivated the initiation of daily conventional hemodialysis (HD) over 10 to 14 days, with a favorable evolution. The following complications were recorded: anemia, bacteremia and deep vein thrombosis. These observations raise three questions in the treatment of paraquat intoxication: the effectiveness of HD, the interest of its association with the above therapies in the prevention of pulmonary fibrosis, and the need for infectious prevention and thromboembolism. Furthermore, the absence of a paraquatemia assay cannot constitute a limitation for management, and hemoperfusion on an inaccessible charcoal column can be replaced by an HD usually available.

Nous rapportons les observations de deux patients ayant ingéré volontairement des doses létales du paraquat à but suicidaire, avec un score pronostic défavorable. Le traitement a consisté en un lavage gastrique, une administration du charbon activé, du n-acétylcystéine et du cyclophosphamide + méthylprednisolone + dexaméthasone. L'installation d'une insuffisance rénale aiguë a motivé l'initiation d'une hémodialyse conventionnelle quotidienne (HD) sur 10 à 14 jours, avec une évolution favorable. Les complications suivantes ont été enregistrées : anémie, bactériémie et thrombose veineuse profonde. Ces observations soulèvent trois questions dans le traitement d'une intoxication au paraquat : l'efficacité de l'HD, l'intérêt de son association avec les thérapeutiques supra dans la prévention de la fibrose pulmonaire, et la nécessité d'une prévention infectieuse et thrombo-embolique. Par ailleurs, l'absence d'un dosage de la paraquatémie ne peut constituer une limite pour la prise en charge, et l'hémoperfusion sur colonne de charbon non accessible peut être remplacée par une HD habituellement disponible.

Relato de caso de intoxicación con superwarfarinas: un desafío terapéutico / Managing Superwarfarin Poisoning: A Challenging Case

La intoxicación humana por rodenticidas anticoagulantes de acción prolongada, conocidos como superwarfarinas, provoca coagulopatía de prolongado manejo. Presentamos el caso de un hombre de 42 años que ingirió una dosis tóxica de rodenticida en un intento suicida, evolucionando con epistaxis, INR de 11,6 y necesidad de hospitalización. Durante 7 días se realizaron controles seriados de pruebas de coagulación, con optimización de diferentes dosis de suplementación de Vitamina K. El caso destaca la potencia y vida media prolongada (aproximadamente 6 semanas) de este tipo de anticoagulantes, hecho que requiere un control clínico regular y una adherencia al tratamiento satisfactoria.

Human intoxication by long-acting anticoagulant rodenticides, known as superwarfarins, causes coagulopathy that is difficult to manage. We present the case of a 42-year-old man who ingested a toxic dose of rodenticide in a suicide attempt, evolving with epistaxis, INR of 11.6, and needing hospitalization. For seven days, serial controls of coagulation tests were carried out, with optimization of different doses of Vitamin K supplementation. The case highlights this type of anticoagulant's potency and prolonged half-life (approximately six weeks), which requires regular clinical control and satisfactory treatment adherence.

Changes in Opioid and Benzodiazepine Poisoning Deaths After Cannabis Legalization in the US: A County-level Analysis, 2002-2020.

BACKGROUND: Cannabis legalization for medical and recreational purposes has been suggested as an effective strategy to reduce opioid and benzodiazepine use and deaths. We examined the county-level association between medical and recreational cannabis laws and poisoning deaths involving opioids and benzodiazepines in the US from 2002 to 2020. METHODS: Our ecologic county-level, spatiotemporal study comprised 49 states. Exposures were state-level implementation of medical and recreational cannabis laws and state-level initiation of cannabis dispensary sales. Our main outcomes were poisoning deaths involving any opioid, any benzodiazepine, and opioids with benzodiazepines. Secondary analyses included overdoses involving natural and semi-synthetic opioids, synthetic opioids, and heroin. RESULTS: Implementation of medical cannabis laws was associated with increased deaths involving opioids (rate ratio [RR] = 1.14; 95% credible interval [CrI] = 1.11, 1.18), benzodiazepines (RR = 1.19; 95% CrI = 1.12, 1.26), and opioids+benzodiazepines (RR = 1.22; 95% CrI = 1.15, 1.30). Medical cannabis legalizations allowing dispensaries was associated with fewer deaths involving opioids (RR = 0.88; 95% CrI = 0.85, 0.91) but not benzodiazepine deaths; results for recreational cannabis implementation and opioid deaths were similar (RR = 0.81; 95% CrI = 0.75, 0.88). Recreational cannabis laws allowing dispensary sales was associated with consistent reductions in opioid- (RR = 0.83; 95% CrI = 0.76, 0.91), benzodiazepine- (RR = 0.79; 95% CrI = 0.68, 0.92), and opioid+benzodiazepine-related poisonings (RR = 0.83; 95% CrI = 0.70, 0.98). CONCLUSIONS: Implementation of medical cannabis laws was associated with higher rates of opioid- and benzodiazepine-related deaths, whereas laws permitting broader cannabis access, including implementation of recreational cannabis laws and medical and recreational dispensaries, were associated with lower rates. The estimated effects of the expanded availability of cannabis seem dependent on the type of law implemented and its provisions.

Jamaican Susumber Berry Poisoning Mimicking Acute Stroke.

BACKGROUND: Stroke mimics are non-vascular conditions that present with acute focal neurological deficits, simulating an acute ischemic stroke. Susumber berry (SB) toxicity is a rare cause of stroke mimic with limited case reports available in the literature. OBJECTIVES: We report four new cases of SB toxicity presenting as stroke mimic, and we performed a systematic review. METHODS: MEDLINE/EMBASE/WoS were searched for "susumber berries," "susumber," or "solanum torvum." RESULTS: 531 abstracts were screened after removal of duplicates; 5 articles and 2 conference abstracts were selected describing 13 patients. A total of 17 patients who ingested SB and became ill were identified, including our 4 patients. All but one presented with acute neurologic manifestation; 16 (94%) presented with dysarthria, 16 (94%) with unstable gait, 8 (47%) with nystagmus/gaze deviation, 10 (59%) with blurry vision, and 5 (29%) with autonomic symptoms. Six (35%) required ICU admission, and 3 (18%) were intubated. Fourteen (82%) had a rapid complete recovery, and 3 were hospitalized up to 1 month. CONCLUSIONS: SB toxicity can cause neurological symptoms that mimic an acute stroke typically with a posterior circulation symptom complex. Altered SB toxins (from post-harvest stressors or temperature changes) might stimulate muscarinic/nicotinic cholinergic receptors or inhibit acetylcholinesterase, causing gastrointestinal, neurological, and autonomic symptoms. In cases of multiple patients presenting simultaneously to the ED with stroke-like symptoms or when stroke-like symptoms fail to localize, a toxicological etiology (such as SB toxicity) should be considered.

Urea poisoning in cattle: a brief review and diagnostic approach / Intoxicação por ureia em bovinos: breve revisão e abordagem diagnóstica

Urea is an organic compound characterized as a white, solid, and hygroscopic substance. It is recognized as a source of non-protein nitrogen (NPN) and is widely used as a partial replacement for protein in cattle diets due to the ability of the ruminal microbiota to convert it into microbial protein. Despite the advantages of using urea, it also has limitations, particularly the proximity between metabolizable and toxic or fatal doses. Furthermore, for safe use, a period of adaptation is necessary for the animals. Poisoning is characterized by rapid and generally fatal development, which is frequent in non-adapted animals but can also occur in those with previous adaptations. The aim of this study was to characterize the clinical, epidemiological, and pathological aspects of urea poisoning through a brief review and a retrospective study. In addition, interviews were conducted with veterinarians who frequently send diagnostic material to the Laboratory of Anatomic Pathology of the "Faculdade de Medicina Veterinária e Zootecnia" (LAP-FAMEZ) to assess their perception of the outbreaks of urea poisoning. The objective was to obtain a comparative scenario between published cases and those received by the laboratory while considering the real situation of this condition in the field. During this retrospective study, only four outbreaks were investigated; in one, the diagnosis was possible through experimental reproduction. Of 35 interviewees, 88.9% said they had seen more than one case compatible with urea poisoning, but 87.5% did not perform a necropsy and/or send material to confirm the diagnosis. The results show that the reality of urea poisoning may be very distant from that reported in previous studies due to the difficulty often observed in the diagnostic approach, so we developed a flowchart aiming to provide a useful guide for field veterinarians.

A ureia é um composto orgânico, que se apresenta como uma substância branca, sólida e higroscópica, e é reconhecida como fonte de nitrogênio não proteico (NNP), sendo amplamente utilizada como fertilizante e também como substituto parcial de proteína em bovinos devido à capacidade da microbiota ruminal de convertê-la em proteína microbiana. Apesar das vantagens que envolvem o uso da ureia, ela também apresenta limitações, a principal delas é a proximidade entre doses metabolizáveis e tóxicas ou fatais, e para que seja utilizada com segurança é necessário um período de adaptação dos animais. A intoxicação é caracterizada por evolução rápida e geralmente fatal, sendo frequente em animais não adaptados, mas pode ocorrer naqueles com adaptação prévia. O objetivo deste estudo é caracterizar os aspectos clínicos, epidemiológicos e patológicos da intoxicação por ureia por meio de uma breve revisão e um estudo retrospectivo. Adicionalmente foram realizadas entrevistas com médicos veterinários que frequentemente enviam material para diagnóstico no Laboratório de Anatomia Patológica da Faculdade de Medicina Veterinária e Zootecnia (LAP-FAMEZ) com o objetivo de avaliar a percepção dos mesmos em relação aos surtos de intoxicação por ureia, na expectativa de se obter um quadro comparativo entre os casos recebidos pelo laboratório e levantamentos publicados e a real situação desta condição a campo. No período do estudo retrospectivo, foram acompanhados apenas quatro surtos, sendo que em um deles foi possível diagnosticar por reprodução experimental. Dos 35 entrevistados, 88,9% afirmaram ter atendido mais de um caso compatível com intoxicação por ureia, mas 87,5% deles não realizaram necropsia e/ou envio de material para confirmação do diagnóstico. Foi possível observar que a realidade da intoxicação por ureia pode estar muito distante daquela relatada em estudos anteriores, e devido à dificuldade muitas vezes observada na abordagem diagnóstica, desenvolvemos um fluxograma na expectativa de que ele constitua um guia útil para veterinários de campo.