Journal of medical toxicology: official journal of the American College of Medical Toxicology

Publisher: University of Pennsylvania. Press

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Other titles Journal of medical toxicology (Online), Journal of medical toxicology
ISSN 1937-6995
OCLC 163567183
Material type Document, Periodical, Internet resource
Document type Internet Resource, Computer File, Journal / Magazine / Newspaper

Publications in this journal

  • [Show abstract] [Hide abstract]
    ABSTRACT: Confusion regarding a drug's active ingredient may lead to simultaneous use of multiple acetaminophen-containing prescriptions and increase the risk of unintentional overdose. The objective of this study was to examine prescription labeling practices for commonly prescribed acetaminophen-containing analgesics, specifically focusing on how active ingredient information and concomitant use warnings were conveyed. Patients with new acetaminophen-containing prescriptions were recruited upon discharge from an emergency department in Chicago or at an outpatient, hospital-based pharmacy in Atlanta. Label information was transcribed from prescription bottles and patients' knowledge of active ingredient was assessed by in-person interviews. Among the 245 acetaminophen-containing prescriptions, hydrocodone was the most common second active ingredient (n = 208, 84.8 %) followed by oxycodone (n = 28, 11.4 %). Acetaminophen was identified by its full name on 6.9 % (n = 17) of labels; various abbreviations were used in 93.1 % of cases. One hundred forty-seven bottles used auxiliary warning labels with the majority of labels (n = 130, 88.4 %) warning about maximum dose and 11.5 % (n = 17) about concomitant use. Most of the study participants (n = 177, 72.2 %) were not able to identify acetaminophen as an active ingredient in their prescription. There was no significant association between the use of unabbreviated labels including warning information and patients' awareness of acetaminophen as an active ingredient (36.4 vs. 27.3 %, p = 0.50). We noted high variability in labeling practices and warning information conveyed to patients receiving acetaminophen-containing prescriptions. Missed opportunities to adequately convey risk information may contribute to the burden of acetaminophen-related liver injury.
    Journal of medical toxicology: official journal of the American College of Medical Toxicology 02/2015;
  • Journal of medical toxicology: official journal of the American College of Medical Toxicology 02/2015;
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    ABSTRACT: Intravenous N-acetylcysteine (NAC) causes few adverse drug events, with mild anaphylactoid reactions being the most common. Hyponatremia as a complication of hypoosmolar NAC solution has been reported. We describe how a locally constructed electronic medical record (EMR) order set for IV NAC resulted in a seizure from hyponatremia due to excess free water administration. A 13-month-old female with no past medical history presented to a hospital after ingesting an unknown number of acetaminophen 500 mg tablets. The 4-h acetaminophen concentration was 343 mcg/mL, and she was started on IV NAC. 8.2 h into her 21-h IV NAC protocol, she developed a tonic-clonic seizure. Repeat serum sodium was 124 mEq/L, a decrease from 142 mEq/L at the time of admission. She was treated with hypertonic saline, lorazepam, and levetiracetam and had no further seizures. A brain MRI and EEG were both normal. After the seizure was stabilized, the providers noticed that the patient had receive a total of 900 mL of D5W (112.5 mL/kg) in the first 9 h of hospitalization. This was caused by a poorly constructed, restrictive, EMR order set that did not allow customization of the IV NAC preparation. Because the 21-h IV NAC administration involves preparation of 3 different doses infused over 3 different time intervals, an order set was developed to reduce ordering errors. However, error in its construction caused the pharmacist to prepare a solution containing too much free water, decreasing patient's intravascular sodium and resulting in a seizure. The purposes of our case report were to highlight the dangers of overreliance on EMR order sets and to recognize hyponatremic seizures as an adverse reaction of an inappropriately prepared IV NAC.
    Journal of medical toxicology: official journal of the American College of Medical Toxicology 01/2015;
  • Journal of medical toxicology: official journal of the American College of Medical Toxicology 12/2014;
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    ABSTRACT: Hong SB, Kim HJ, Huh JW, et al.: A cluster of lung injury associated with home humidifier use: clinical, radiological and pathological description of a new syndrome. Thorax 2014; 69: 694–702.Background: This case series described a cluster of previously healthy adults who were admitted to a Korean intensive care unit for severe respiratory distress. All cases occurred over a several month period in 2011, some of which progressed to death. In-depth diagnostic testing did not reveal an infectious etiology.Research Question: The goal of the authors, along with the Korean Centers for Disease Control, was to investigate the cause of respiratory disease in a cluster of previously healthy patients.Methods: A multidisciplinary team, developed and chaired by the authors, was established to review the clinical features, laboratory, radiographic, and pathology findings for all cases. This team included pulmonologists, radiologists, and pathologists. A case was retrospectively defined as any patie ...
    Journal of medical toxicology: official journal of the American College of Medical Toxicology 12/2014;
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    ABSTRACT: The anticholinergic toxidrome is well described and relatively common. Despite controversy, studies have shown that physostigmine is relatively safe and effective in reversing this toxidrome. We would expect toxicologists would be liberal in its use. We retrospectively analyzed data in the Toxicology Investigators Consortium (ToxIC) registry, representing data from medical toxicologists in multiple institutions nationwide, searching for patients who exhibited an anticholinergic toxidrome, determining what treatment(s) they received, and classifying the treatments as physostigmine, benzodiazepines, physostigmine and benzodiazepines, antipsychotics, or no definitive treatment. The causal agents of the toxidrome were as reported by the treating toxicologist. Eight hundred fifteen consecutive patients with anticholinergic toxidromes were analyzed. Benzodiazepines alone were given in 28.7 %, 12.4 % were given physostigmine alone, 8.8 % received both physostigmine and benzodiazepines, 2.7 % were given antipsychotics, and 47.4 % were given no definitive treatment. In patients who received only physostigmine, there was a significant difference in the rate of intubation (1.9 vs. 8.4 %, OR 0.21, 95 % CI 0.05-0.87) versus other treatment groups. Physostigmine was given at varying rates based on causative agent with use in agents with mixed or unknown effects (15.1 %) being significantly lower than those with primarily anticholinergic effects (26.6 %) (p < 0.001). Patients with anticholinergic toxicity were more likely to receive benzodiazepines than physostigmine. Those patients who received only physostigmine had a significantly lower rate of intubation. Physostigmine was more likely to be used with agents exerting primarily anticholinergic toxicity than in those agents with multiple actions.
    Journal of medical toxicology: official journal of the American College of Medical Toxicology 12/2014;
  • Journal of medical toxicology: official journal of the American College of Medical Toxicology 12/2014;
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    ABSTRACT: Chronic pain is a common reason for emergency department (ED) visits. Our objective was to describe opioid prescribing practices of ED providers when treating patients with chronic pain. We retrospectively evaluated opioid prescriptions from EDs at two tertiary care military hospitals. We queried the outpatient record database to obtain a list of opioid medications prescribed and ICD-9 codes associated with visits for chronic pain. We collected provider type and gender, number of pills, opioid type, and refills. We compared the incidence with chi-square or Fisher's exact tests. Wilcoxon test was used for non-parametric continuous variables. Over 3 years, 28,103 visits generated an opioid prescription. One thousand three hundred twenty-two visits were associated with chronic pain, and 443 (33 %) visits were associated with an opioid prescription. Providers were 79 % physicians, 19 % physician assistants (PAs), 81 % male, and 69 % active duty military. Medications were 43 % oxycodone, 30 % hydrocodone, 9.5 % tramadol, 2.5 % codeine, and 15 % other. The number of pills was 20 [interquartile range (IQR) 15-30] (range 1-240), morphine equivalents (M.E.) per pill was 7.5 [7.5-7.5] (2.5-120) and total M.E. per prescription was 150 [112.5-270] (15-6000). Physicians were more likely to prescribe a non-opioid than PAs (77 vs 45 %, p < 0.0001). Civilian providers were more likely to prescribe an opioid than active duty providers (58 vs 42 %, p < 0.0001). Providers prescribed a median of 20 pills per prescription and most commonly prescribed oxycodone. PAs were more likely to prescribe an opioid for chronic pain than physicians. Civilian providers were more likely to prescribe an opioid than active duty providers.
    Journal of medical toxicology: official journal of the American College of Medical Toxicology 12/2014;
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    ABSTRACT: Carpet vipers (Echis) are found across the semiarid regions of west, north, and east Africa; west, south, and east Arabia; parts of Iran and Afghanistan north to Uzbekistan; and in Pakistan, India, and Sri Lanka. Recently, a new species belonging to the Echis genus, Echis omanensis has been recognized in Oman. Not much is known about the clinical manifestations of envenomation from its bite. A 63-year-old snake keeper presented to the emergency department shortly after being bitten by an Oman carpet viper (E. omanensis). The incident occurred during expression of the venom at a research center. The patient complained of severe pain and swelling of the left index finger, which extended to the mid-forearm within 1 h. His vital signs remained stable, with no evidence of systemic manifestations. He was treated initially with analgesics and tetanus toxoid. Due to rapidly progressive swelling and the potential for a delayed coagulopathy, the Saudi National Guard polyvalent snake antivenom was administered according to the Ministry of Health protocol. The patient was admitted to the intensive care unit, remained hemodynamically stable, and had normal serial coagulation tests, with subsequent resolution of the swelling. We report the first case of an E. omanensis bite in which the patient developed rapidly progressive local toxicity, which improved after administration of the Saudi polyvalent antivenom.
    Journal of medical toxicology: official journal of the American College of Medical Toxicology 11/2014;
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    ABSTRACT: The NBOMes (N-benzyl-oxy-methyl derivatives of known 2C phenylethylamines) are a new and growing class of potent synthetic stimulants. Case reports provide the bulk of available safety and clinical data for clinicians. We report two cases of NBOMe intoxication with 25C-NBOMe (the first lab-confirmed US case) and 25B-NBOMe, respectively, both confirmed via triple quadrapole mass spectrometry.
    Journal of medical toxicology: official journal of the American College of Medical Toxicology 11/2014;
  • Journal of medical toxicology: official journal of the American College of Medical Toxicology 10/2014;
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    ABSTRACT: Citalopram is a selective serotonin reuptake inhibitor (SSRI) with cardiac and neurologic toxicities as well as the potential for serotonin syndrome. In most instances, patients recover fully from toxic ingestions of SSRIs. We describe a fatal case of a citalopram overdose.
    Journal of medical toxicology: official journal of the American College of Medical Toxicology 10/2014;
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    ABSTRACT: Phenol is a caustic that may cause cutaneous or gastrointestinal burns depending on the route of exposure. Significant absorption may result in systemic toxicity. We present a case of topical phenol exposure resulting in cutaneous burns and systemic phenol toxicity.
    Journal of medical toxicology: official journal of the American College of Medical Toxicology 10/2014;
  • Journal of medical toxicology: official journal of the American College of Medical Toxicology 10/2014;
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    ABSTRACT: Pancreatitis and laboratory interference are rarely reported complications of intravenous lipid emulsion (ILE) therapy. We report a case of significant laboratory interference after ILE administration.
    Journal of medical toxicology: official journal of the American College of Medical Toxicology 10/2014;
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    ABSTRACT: Elevated concentrations of serum acetaminophen-protein adducts, measured as protein-derived acetaminophen-cysteine (APAP-CYS), have been used to support a diagnosis of APAP-induced liver injury when histories and APAP levels are unhelpful. Adducts have been reported to undergo first-order elimination, with a terminal half-life of about 1.6 days. We wondered whether renal failure would affect APAP-CYS elimination half-life and whether continuous venovenous hemodiafiltration (CVVHDF), commonly used in liver failure patients, would remove adducts to lower their serum concentrations. Terminal elimination half-lives of serum APAP-CYS were compared between subjects with and without renal failure in a prospective cohort study of 168 adults who had ingested excessive doses of APAP. APAP-CYS concentrations were measured in plasma ultrafiltrate during CVVHDF at times of elevated serum adduct concentrations. Paired samples of urine and serum APAP-CYS concentrations were examined to help understand the potential importance of urinary elimination of serum adducts. APAP-CYS elimination half-life was longer in 15 renal failure subjects than in 28 subjects with normal renal function (41.3 ± 2.2 h versus 26.8 ± 1.1 h [mean ± SEM], respectively, p < 0.001). CVVHDF failed to remove detectable amounts of APAP-CYS in any of the nine subjects studied. Sixty-eight percent of 557 urine samples from 168 subjects contained no detectable APAP-CYS, despite levels in serum up to 16.99 μM. Terminal elimination half-life of serum APAP-CYS was prolonged in patients with renal failure for reasons unrelated to renal urinary adduct elimination, and consideration of prolonged elimination needs to be considered if attempting back-extrapolation of adduct concentrations. CVVHDF did not remove detectable APAP-CYS, suggesting approximate APAP-protein adduct molecular weights ≥ 50,000 Da. The presence of urinary APAP-CYS in the minority of instances was most compatible with renal adduct production and protein shedding into urine rather than elimination of serum adducts.
    Journal of medical toxicology: official journal of the American College of Medical Toxicology 10/2014;