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1.  Recurrent Seizures and Serotonin Syndrome Following “2C-I” Ingestion 
Journal of Medical Toxicology  2013;9(2):196-198.
The phenethylamines, including 2, 5 dimethoxy-4-iodophenethylamine, commonly referred to as 2C-I, have recently emerged as a new class of designer drugs. Cases of toxicity from these drugs are not well described in the literature. This case report describes a 19 year-old male who insufflated 2C-I. Following the ingestion, the patient developed recurrent seizures, and was taken to the emergency department, where he was noted to be hyperadrenergic and had recurrent seizures. The patient was diagnosed with serotonin syndrome and experienced prolonged respiratory failure, although he ultimately made a full recovery. Comprehensive drug testing revealed the presence of 2C-I. The pharmacologic properties of 2C-I are also discussed.
PMCID: PMC3657032  PMID: 23378129
Serotonin syndrome; 2C-I; 2CI; Phenethylamine; Seizure; Rave
2.  Plasma and Urine Dimercaptopropanesulfonate Concentrations after Dermal Application of Transdermal DMPS (TD-DMPS) 
2,3-Dimercaptopropane-1-sulfonate (DMPS) is a metal chelator approved in Europe for oral or intravenous use for heavy metal poisoning. Transdermally applied DMPS (TD-DMPS) is used by some alternative practitioners to treat autism, despite the absence of evidence for its efficacy. We found no literature evaluating the pharmacokinetics of the transdermal route of delivery or the ability of TD-DMPS to enhance urinary mercury elimination. We hypothesized that TD-DMPS is not absorbed. Eight adult volunteers underwent application of 1.5–3 drops/kg of TD-DMPS. Subjects provided 12-h urine collections the day before and day of application. Subjects underwent blood draws at 0, 30, 60,90, 120, and 240 min after TD-DMPS application. Plasma and urine were assayed for the presence of DMPS. Urine was assayed for any change in urinary mercury excretion after DMPS. One control subject ingested 250 mg of oral DMPS and underwent the same urine and blood collections and analyses. No subject had detectable urine DMPS or increased urine mercury excretion after TD-DMPS. One subject had detectable levels of DMPS in the 30-min plasma sample, suspected to be contamination. All other samples for that subject and the other seven subjects showed no detectable plasma DMPS. The control subject had detectable urine and plasma DMPS levels and increased urine mercury excretion. These results indicate that TD-DMPS is not absorbed. There was no increase in urine mercury excretion after TD-DMPS. Our results argue that TD-DMPS is an ineffective metal chelator.
PMCID: PMC3576508  PMID: 23143832
DMPS; Chelation; Mercury; Autism
3.  Influence of Drug Use on Morbidity and Mortality in Heatstroke 
Journal of Medical Toxicology  2012;8(3):252-257.
Numerous medications and illicit drugs can predispose an individual to heat illness, primarily by altering thermoregulation by either increasing endogenous heat production or impairing heat dissipation. This study sought to determine if use of such drugs was associated with more severe illness in patients presenting with heatstroke. A case control study was conducted on adult patients (age, ≥14 years) admitted to an intensive care unit with an admitting diagnosis of heatstroke at two academic teaching hospitals in Phoenix, AZ, between 31 August 2005 through 31 July 2010. Subjects were classified as “users” if they admitted to taking a drug on a pre-defined list of drugs associated with abnormal thermal homeostasis, or if a urine test for drugs of abuse revealed the presence of an amphetamine or cocaine. Similarly, subjects who did not take such drugs were considered “non-users.” Seventy-eight patients were identified, with complete medication histories available for 74 of 78 subjects. The overall prevalence of drug utilization was 41.9 % (31 of 74). The median length of stay was 3.0 days for the non-users compared with 9.0 days for “users.” There was no difference between users and non-users with regard to mortality. Drugs that impair thermoregulation are frequently encountered in patients admitted for heatstroke. Patients taking such drugs may experience increased morbidity over those patients not taking such drugs.
PMCID: PMC3550168  PMID: 22447633
Heatstroke; Heat illness; Drugs; Heat; Medications
4.  Outcomes of Unintentional beta-Blocker or Calcium Channel Blocker Overdoses: a Retrospective Review of Poison Center Data 
Journal of Medical Toxicology  2012;8(2):135-139.
Outcomes following unintentional, supratherapeutic ingestions of a patient’s own beta-blocker (BB) or calcium channel blocker (CCB) have not been well studied. A retrospective review of all poison control center (PCC) charts from January 2007 through December 2009 yielded 4,099 cases involving a BB or CCB. Of these, 436 (10.6%) met inclusion criteria. Data abstracted included patient age/gender, medication(s) involved, dose(s), time interval between ingestions, symptoms, and outcome. Exclusion criteria included intentional ingestions, ingesting someone else’s medication, and ingestion intervals >12 h. Outcomes were defined as the development of symptoms, management site, hospital admission, and death. Mean age was 65.1 years (range 2–91; SD 17.9); 284 (65.1%) were women. Eighty-two (18.8%) cases resulted in ED evaluation; 44 (53.7%) of these were referred in by the PCC. Symptoms developed in 44 (10.1%) cases and 32 (7.3%) were admitted due to the ingestion. Of those admitted, five (15.6%) received treatment (three intravenous fluids, one glucagon, one calcium). Of the 343 (78.7%) cases initially observed on site, three (0.9%) were later referred to an ED; none required treatment. There was one death under extenuating circumstances. The validity of data abstraction was determined for six variable using 43 charts [0.97; 95% CI (0.91–0.99)]. Based on a retrospective analysis of PCC cases, home observation of asymptomatic patients following unintentional supratherapeutic ingestions of their own BB or CCB was safe in most cases. Further, prospective study is required to identify risks factors for becoming symptomatic or requiring treatment.
PMCID: PMC3550234  PMID: 22311669
beta-Blocker toxicity; Calcium channel blocker toxicity; Poison center utilization; Management of unintentional ingestions
5.  A Survey of Primary Care Offices: Triage of Poisoning Calls without a Poison Control Center 
Poison control centers hold great potential for saving health care resources particularly by preventing unnecessary medical utilization. We developed a four-question survey with three poisoning-related scenarios, based on common calls to our poison center, and one question regarding after-hours calls. We identified primary care provider offices in our poison center's region from an internet search. We contacted these offices via telephone and asked to speak to an office manager or someone responsible for triaging patient phone queries. Using a scripted form, trained investigators questioned 100 consecutive primary care provider offices on how they would handle these poisoning-related calls if there was no poison center to refer their patients to. Results of our survey suggest that 82.5% of poisoning-related calls to primary care offices would be referred to 911 or an emergency department if there was no poison center. These results further support the role that poison centers play in patient care and health care utilization.
PMCID: PMC3395190  PMID: 22811902
6.  Patient preferences for emergency department-initiated tobacco interventions: a multicenter cross-sectional study of current smokers 
The emergency department (ED) visit provides a great opportunity to initiate interventions for smoking cessation. However, little is known about ED patient preferences for receiving smoking cessation interventions or correlates of interest in tobacco counseling.
ED patients at 10 US medical centers were surveyed about preferences for hypothetical smoking cessation interventions and specific counseling styles. Multivariable linear regression determined correlates of receptivity to bedside counseling.
Three hundred seventy-five patients were enrolled; 46% smoked at least one pack of cigarettes per day, and 11% had a smoking-related diagnosis. Most participants (75%) reported interest in at least one intervention. Medications were the most popular (e.g., nicotine replacement therapy, 54%), followed by linkages to hotlines or other outpatient counseling (33-42%), then counseling during the ED visit (33%). Counseling styles rated most favorably involved individualized feedback (54%), avoidance skill-building (53%), and emphasis on autonomy (53%). In univariable analysis, age (r = 0.09), gender (average Likert score = 2.75 for men, 2.42 for women), education (average Likert score = 2.92 for non-high school graduates, 2.44 for high school graduates), and presence of smoking-related symptoms (r = 0.10) were significant at the p < 0.10 level and thus were retained for the final model. In multivariable linear regression, male gender, lower education, and smoking-related symptoms were independent correlates of increased receptivity to ED-based smoking counseling.
In this multicenter study, smokers reported receptivity to ED-initiated interventions. However, there was variability in individual preferences for intervention type and counseling styles. To be effective in reducing smoking among its patients, the ED should offer a range of tobacco intervention options.
PMCID: PMC3414814  PMID: 22966410
Smoking; Tobacco; Cigarettes; Emergency medicine; Counseling; Patient preference
7.  Poison control centers decrease emergency healthcare utilization costs 
Journal of Medical Toxicology  2008;4(4):221-224.
Patient home management by a regional poison control center has potential to save public healthcare dollars by preventing unnecessary utilization of emergency department services. We wished to conservatively quantify such savings at a large regional poison center and compare savings to funds received in state support.
Banner Poison Control Center (BPCC) serves a population of about four million in central AZ. A telephone survey of callers who were managed at home in February and March of 2007 after nontoxic exposures was used to calculate what percentage of such callers would have sought unnecessary medical care in emergency departments. Twelve emergency departments geographically dispersed in the region were surveyed, and a state database of hospital charges was queried to determine hospital charges and physician professional charges for conservative management of a patient who would have been advised to remain at home by BPCC.
BPCC managed 28,883 callers at home in 2007. Seventy percent of home-managed patients would have sought unnecessary care in emergency departments. Using most conservative assumptions, a median of $33 million [range $18 million to $45 million] in unnecessary health care charges were prevented by BPCC home-management in 2007. A median of about $36 in unnecessary health care charges were prevented for each dollar of state funding BPCC received.
Home management by BPCC provides large dollar savings to residents compared to dollars received in state support.
PMCID: PMC3550108  PMID: 19031372
Poison control centers; health care utilization; cost savings
8.  Accidental dextromethorphan ingestions in children less than 5 years old 
Journal of Medical Toxicology  2008;4(4):251-253.
The purpose of this study is to evaluate the clinical presentation of accidental dextromethorphan (DXM) ingestions in children <5 years old. Two consecutive years of poison center patient encounters were reviewed. Data including age, outcomes, amount of DXM ingested, co-ingestions, vital signs, clinical manifestations, hospital admissions, and mortality were abstracted. Data were analyzed using descriptive statistics.
A total of 304 cases were identified with a mean age of 28.2 months (72% were ≥23 months). All cases co-ingested other products of over-the-counter cough and cold medications (i.e., acetaminophen, pseudoephedrine, guaifenesin, ibuprofen, various H1 receptor antagonists, and very infrequently ethanol). The mean DXM dose ingested was 35.0 mg (2.64 mg/kg). Of the patients, 62 (20.4%) experienced lethargy as the sole neurological sign and no patient had any cardiovascular abnormalities. Only 1 (13-month-old) patient, who ingested 3.2 mg/kg and presented with lethargy, was hospitalized and subsequently discharged 14 hours later. No deaths were recorded.
As demonstrated in our patient population, accidental ingestions of DXM in the pediatric patient did well with supportive care alone and rarely required inpatient treatment.
PMCID: PMC3550111  PMID: 19031376
Dextromethorphan; pediatrics; ingestion
9.  Four-year experience with methotrexate exposures 
Journal of Medical Toxicology  2008;4(3):149-150.
Unintentional methotrexate (MTX) acute oral overdose is rarely reported.
We conducted a retrospective chart review of all human exposure calls (> 150,000 charts) for MTX ingestions reported to our Poison Center during 2000–2003.
Thirteen patients met the criteria. The average amount of MTX ingested was 13.03 mg (data from 7 cases), and the average patient age was 43 years (20 months to 80 years). No significant toxicities occurred.
Although intravenous MTX toxicity can be severe, this does not appear to be a phenomenon associated with either acute unintentional or suicidal oral ingestion.
PMCID: PMC3550042  PMID: 18821486
methotrexate; poisoning; toxicity; oral
10.  Reversible cardiomyopathy complicating intrathecal baclofen withdrawal: A case report 
Journal of Medical Toxicology  2007;3(4):187-189.
This case report is about reversible cardiomyopathy associated with intrathecal baclofen withdrawal. Previous literature has reported that enteral baclofen does not adequately control intrathecal baclofen withdrawal. In our case, coronary atherosclerosis did not play a role in the development of the cardiomyopathy. However, reinstitution of intrathecal baclofen promptly resulted in improvement. One could hypothesize that myocardial stunning from sympathetic hyperactivity led to a similar cardiomyopathy reported with catecholamine excess or acute sympathomimetic poisoning.
PMCID: PMC3550018  PMID: 18072175
baclofen withdrawal; cardiomyopathy; intrathecal
11.  The feasibility of administration of activated charcoal with respect to current practice guidelines in emergency department patients 
Journal of Medical Toxicology  2007;3(3):100-102.
The American Academy of Clinical Toxicology, European Association of Poisons Centres, and Clinical Toxicologists recommend administration of activated charcoal (AC) within one-hour of an acute toxic ingestion [1]. Our poison control center periodically and upon request faxes an abbreviated protocol to hospital emergency departments, reminding physicians of these current AC recommendations. This study was conducted to describe how often patients present within the one-hour time frame and how often the guidelines in the above position statement are being followed.
Following a brief training of systematic chart review, reviewers blinded to the purpose of the study completed a standardized data collection sheet. Three years after publication of these consensus statements, a period of 3 consecutive years of poison center patient encounters were reviewed. Recorded data included age, outcomes, and time to administration of charcoal.
Approximately 150,000 reported toxic exposures were reviewed, of which 16,914 patients of acute ingestions presented to a health care facility. The mean age of the group that presented was 25 years [range 1 month-87 years]. A total of 2,700 (16%) patients that presented were within 60 minutes of an acute overdose and all were administered AC in accordance with the recommended guidelines. Interestingly, pre-hospital personnel administered AC within 60 minutes to 762 (28% of 2,700) patients. Correspondingly, 14,214 (84%) patients presented more than 60 minutes after an acute overdose. Of this latter group AC was withheld in 341 (2.4% of 14,214) patients, and 13,873 (97.6% of 14,214) patients received charcoal despite having arrived more than 60 minutes after ingestion. The mean time to the first administration of AC in this latter group was 225 minutes [range of 61–2160 minutes] following ingestion.
Only a small percentage of patients treated for an acute overdose (16%) present within 60 minutes and are given charcoal according to the current guidelines. A large subset of these patients (28%) is given AC in a pre-hospital setting. Few patients presenting to a health care provider after an acute toxic ingestion are treated in accordance with the current recommendations for activated charcoal.
PMCID: PMC3550070  PMID: 18072144
charcoal; activated charcoal

Results 1-11 (11)