Current Awareness in Clinical Toxicology Editors: Damian Ballam Msc and Allister Vale MD
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Current Awareness in Clinical Toxicology Editors: Damian Ballam MSc and Allister Vale MD November 2015 CONTENTS General Toxicology 7 Metals 34 Management 17 Pesticides 36 Drugs 19 Chemical Warfare 39 Chemical Incidents & 28 Plants 39 Pollution Chemicals 29 Animals 40 CURRENT AWARENESS PAPERS OF THE MONTH An outbreak of acute delirium from exposure to the synthetic cannabinoid AB-CHMINACA Tyndall JA, Gerona R, De Portu G, Trecki J, Elie M-C, Lucas J, Slish J, Rand K, Bazydlo L, Holder M, Ryan MF, Myers P, Iovine N, Plourde M, Weeks E, Hanley JR, Endres G, Germaine DST, Dobrowolski PJ, Schwartz M. Clin Toxicol 2015; online early: doi: 10.3109/15563650.2015.1100306: Background Synthetic cannabinoid containing products are a public health threat as reflected by a number of outbreaks of serious adverse health effects over the past 4 years. The designer drug epidemic is characterized by the rapid turnover of synthetic cannabinoid compounds on the market which creates a challenge in identifying the particular etiology of an outbreak, confirming exposure in cases, and providing current information to law enforcement. Results Between 28 May 2014 and 8 June 2014, 35 patients were evaluated and treated at the University of Florida Health Medical Center in Gainesville following reported exposure to a synthetic cannabinoid containing product obtained from a common source. Patients Current Awareness in Clinical Toxicology is produced monthly for the American Academy of Clinical Toxicology by the Birmingham Unit of the UK National Poisons Information Service, with contributions from the Cardiff, Edinburgh, and Newcastle Units. The NPIS is commissioned by Public Health England 2 demonstrated acute delirium (24) and seizures (14), and five required ventilator support and ICU-level care; none died. The presence of N-[(1S)-1-(aminocarbonyl)-2-methylpropyl]-1- (cyclohexylmethyl)-1H-indazole-3-carboxamide (AB-CHMINACA), or one of its predicted metabolites was confirmed in 15 of 21 cases. A rapid public health response and aggressive public messaging prevented further morbidity, identified the source, and led to law enforcement seizure of the implicated product. Discussion The significance of this outbreak lies as much in the rapid occurrence of unpredictable, life- threatening adverse health effects from a newly identified synthetic cannabinoid compound as it does in the multidisciplinary investigation and novel partnership between local public health, the laboratory, and the chemical industry, resulting in termination of the outbreak. Conclusion A coordinated response and collaboration between law enforcement, the local public health, emergency medical services and Health Center staff, were all key interventions in preventing a more substantial public health outbreak resulting from use of a novel synthetic cannabinoid compound. Real time collaborations between toxicology laboratories, suppliers of analytical standards and the public health system may be useful in the face of future novel chemical exposures. Full text available from: http://dx.doi.org/10.3109/15563650.2015.1100306 A systematic review of adverse events arising from the use of synthetic cannabinoids and their associated treatment Tait RJ, Caldicott D, Mountain D, Hill SL, Lenton S. Clin Toxicol 2015; online early: doi: 10.3109/15563650.2015.1110590: Context Synthetic cannabinoids (SCs) such as "Spice", "K2", etc. are widely available via the internet despite increasing legal restrictions. Currently, the prevalence of use is typically low in the general community (<1%) although it is higher among students and some niche groups subject to drug testing. Early evidence suggests that adverse outcomes associated with the use of SCs may be more prevalent and severe than those arising from cannabis consumption. Objectives To identify systematically the scientific reports of adverse events associated with the consumption of SCs in the medical literature and poison centre data. Method We searched online databases (Medline, PsycInfo, Embase, Google Scholar and Pubmed) and manually searched reference lists up to December 2014. To be eligible for inclusion, data had to be from hospital, emergency department, drug rehabilitation services or poison centre records of adverse events involving SCs and included both self-reported and/or analytically confirmed consumption. Results From 256 reports, we identified 106 eligible studies including 37 conference abstracts on about 4000 cases involving at least 26 deaths. Major complications include cardiovascular events (myocardial infarction, ischemic stroke and emboli), acute kidney injury (AKI), generalized tonic-clonic seizures, psychiatric presentations (including first episode psychosis, paranoia, self-harm/suicide ideation) and hyperemesis. However, most presentations were 3 not serious, typically involved young males with tachycardia (37–77%), agitation (16– 41%) and nausea (13–94%) requiring only symptomatic care with a length of stay of less than 8 hours. Conclusions SCs most frequently result in tachycardia, agitation and nausea. These symptoms typically resolve with symptomatic care, including intravenous fluids, benzodiazepines and anti- emetics, and may not require inpatient care. Severe adverse events (stroke, seizure, myocardial infarction, rhabdomyolysis, AKI, psychosis and hyperemesis) and associated deaths manifest less commonly. Precise estimates of their incidence are difficult to calculate due to the lack of widely available, rapid laboratory confirmation, the variety of SC compounds and the unknown number of exposed individuals. Long-term consequences of SCs use are currently unknown. Full text available from: http://dx.doi.org/10.3109/15563650.2015.1110590 Acute recreational drug and new psychoactive substance toxicity in Europe: 12 months data collection from the European Drug Emergencies Network (Euro-DEN) Dines AM, Wood DM, Yates C, Heyerdahl F, Hovda KE, Giraudon I, Sedefov R, Dargan PI. Clin Toxicol 2015; 53: 893-900. Context Despite the potential for recreational drugs and new psychoactive substances (NPSs) to cause significant morbidity and mortality, there is limited collection of systematic data on acute drug/NPS toxicity in Europe. Objective To report data on acute drug/NPS toxicity collected by a network of sentinel centres across Europe with a specialist clinical and research interest in the acute toxicity of recreational drugs and NPS to address this knowledge gap. Methods Sixteen sentinel centres in 10 European countries (Denmark, Estonia, France, Germany, Ireland, Norway, Poland, Spain, Switzerland and the UK) collected data on all acute drug toxicity presentations to their Emergency Rooms (ERs) for 12 months (October 2013– September 2014); information on the drug(s) involved in the presentations was on the basis of patient self-reporting. Results Data were collected on a total of 5529 presentations involving 8709 drugs (median (interquartile range [IQR]): 1 (1–2) drugs per presentation), a median of 0.3% of all ER attendances. Classical recreational drugs were most common (64.6%) followed by prescription drugs (26.5%) and NPS (5.6%). The 'top five' drugs recorded were heroin (1345 reports), cocaine (957), cannabis (904), GHB/GBL (711) and amphetamine (593). 69.5% of individuals went to hospital by ambulance (peak time between 19:00 and 02:00 at weekends); the median (IQR) age was 31 (24-39) years and 75.4% were male. Although serious clinical features were not seen in most presentations and 56.9% were medically discharged from the ER (median length of stay: 4.6 hours), a significant number (26.5%) was agitated, in 10.5% the GCS was 8 or less and 35 presented in cardiac arrest. There were 27 fatalities with opioids implicated in 13. Conclusion The Euro-DEN dataset provides a unique insight into the drugs involved in and clinical 4 pattern of toxicity/outcome of acute recreational drug toxicity presentations to hospitals around Europe. This is complimentary to other indicators of drug-related harm and helps to build a fuller picture of the public health implications of drug use in Europe. Full text available from: http://dx.doi.org/10.3109/15563650.2015.1088157 Abuse, misuse, and suicidal substance use by children on school property Vakkalanka JP, King JD, Holstege CP. Clin Toxicol 2015; 53: 901-7. Objective The purpose of this study was to characterize the epidemiological trends associated with substances used in intentional exposures among children while on school property reported to the U.S. National Poison Data System (NPDS). Materials and Methods NPDS was queried for intentional (abuse, misuse, suspected suicide, and unknown intentional) exposures reported to occur on school property between calendar years 2004 and 2013. Records were restricted to children 6–18 years of age. Demographic, exposure, and clinical characteristics were assessed. Results A total of 56,882 substances were intentionally used on school property by 50,379 children, of which 39.8% were females (n = 20,070), 57.7% were males (n = 29,084), and 2.4% were unknown gender (n = 1,225). The most frequent pharmaceutical exposures reported included sedatives (n = 4,096; 8.1%), analgesics (n = 4,022; 8.0%), and cough and cold preparations (n = 3,529; 7.0%). The majority of exposures were managed on site (n = 21,464; 42.6%), followed by care at a healthcare facility (n = 20,048; 39.7%). Serious outcomes (moderate or major effects and death) accounted for nine percent of all reported exposures. Compared to reference groups, female gender, teenagers