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Introduction: This is the 41st Annual Report of America's Poison Centers® National Poison Data System®. As of 1 January, 2023, all 55 of the nation's poison centers uploaded case data automatically to NPDS. Methods: We analyzed the case data, tabulating specific indices from the NPDS®. The methodology was as in previous years. Where changes were introduced, the differences are identified. Cases with medical outcomes of death were evaluated by a team of medical and clinical toxicologists using an ordinal scale of 1-6 to assess the Relative Contribution to Fatality of the exposure. Results: In 2023, 2,421,251 closed encounters were logged by the National Poison Data System®: 2,080,659 human exposures, 41,857 animal exposures, 293,663 information requests, 5,046 human confirmed nonexposures, and 26 animal confirmed nonexposures. The upload interval was 4.88 [4.43, 9.33] (median [25%, 75%]) minutes, creating a near real-time national exposure and information database and surveillance system. Total encounters showed a 2.49% decrease from 2022 while human exposure cases increased by 0.764% and health care facility human exposure cases increased by 2.38%. All information requests decreased by 19.1%, medication identification (Drug ID) requests decreased by 14.0%, and medical information requests showed a 61.3% decrease, returning to pre-COVID-19 pandemic numbers. Drug Information requests showed a 17.6% decrease, due to continued declining COVID-19 vaccine calls to poison centers, but these still comprised 21.7% of all information contacts. Human exposures with less serious outcomes have decreased by 1.58% per year since 2008, while those with more serious outcomes (moderate, major or death) have increased by 4.25% per year since 2000. Consistent with the previous year, the top 4 substance classes most frequently involved in all human exposures were analgesics (11.00%), household cleaning substances (7.12%), antidepressants (5.58%), and cosmetics/personal care products (5.01%). Cardiovascular drugs (4.97%) replaced antihistamines as the 5th most common substance class. As a class, analgesic exposures increased most rapidly, by 1,260 cases/year (2.72%/year) over the past 10 years for cases with more serious outcomes. The top 5 most common exposures in children aged 5 years or less were household cleaning substances (10.1%), analgesics (9.13%), cosmetics/personal care products (9.10%), foreign bodies/toys/miscellaneous (8.03%), and dietary supplements/herbals/homeopathic (6.88%). The National Poison Data System® documented 3,272 human exposures resulting in death; 2,700 (82.5%) of these were judged as related (Relative Contribution to Fatality of 1-Undoubtedly responsible, 2-Probably responsible, or 3-Contributory). Conclusions: These data support the continued value of poison center expertise and the need for specialized medical toxicology information to manage the increasing number of more serious exposures. Unintentional and intentional exposures continue to be a significant cause of morbidity and mortality in the US. The near real-time nature of the National Poison Data System® represents a national public health resource for collecting and monitoring US exposure cases and information requests. The continuing mission of the National Poison Data System® is to provide a nationwide infrastructure for surveillance for all types of exposures (e.g., foreign body, infectious, venomous, chemical agent, or commercial product), and the identification and tracking of significant public health events. The National Poison Data System® is a model system for the near real-time surveillance of national and global public health. [ABSTRACT FROM AUTHOR]

The given text is a compilation of case reports and studies related to toxicology and poisoning. It covers a range of topics, including medication overdoses, adverse effects of substances, and the management of toxic exposures. The document provides valuable insights into the complexities of toxicology and highlights the importance of prompt and individualized treatment approaches. It can be a useful resource for library patrons conducting research in this field. [Extracted from the article]

Phenibut is an unregulated supplement that acts primarily as a gamma-aminobutyric acid type B receptor agonist. Use of phenibut can lead to dependence and subsequent withdrawal when use is stopped. Phenibut withdrawal can cause severe symptoms such as delirium, hallucinations, and seizures. The purpose of this systematic review is to characterize the natural history of phenibut withdrawal and summarize treatment strategies published in the literature. A systematic review was conducted using the preferred reporting items for systematic reviews and meta-analyses checklist. English language peer-reviewed articles or conference abstracts in humans describing phenibut withdrawal after cessation of use were included. Databases (Ovid/MEDLINE, Web of Science, and Science Direct) and references of included articles were searched. Case reports were appraised using the Joanna Briggs Institute critical appraisal checklist for case reports. Patient demographics and key outcomes, including withdrawal characteristics and treatment characteristics, were collected into a predefined data collection sheet by six independent reviewers. Search results yielded 515 articles of which 25 were included. All articles were case reports or published conference abstracts. All of the cases (100 percent) involved male patients and the median age was 30 years, (interquartile range 23.5–34 years, range 4 days−68 years). The median daily phenibut dose prior to experiencing withdrawal was 10 g (interquartile range 4.75–21.5 g, range 1–200 g). The shortest duration of phenibut use (2–3 g daily) prior to withdrawal was one week. Withdrawal symptoms occurred as quickly as two hours after the last phenibut dose. Sixteen patients (64 percent) reported progression of withdrawal severity within the first 24 hours of healthcare contact. Seizures were reported in two patients (8 percent), intubation in six patients (24 percent), and intensive care unit admission in 11 patients (44 percent). Withdrawal patterns and outcomes were similar in those using phenibut alone and those with comorbid polysubstance use. Withdrawal treatment strategies varied widely. Only three cases (12 percent) were managed outpatient and all three utilized a phenibut tapering strategy. All patients undergoing medication-assisted abstinence were admitted inpatient for symptom management and received a drug that acts on gamma-aminobutyric acid receptors. The most commonly used medication was a benzodiazepine, reported in 17 cases (68 percent). Nineteen patients (76 percent) required at least two drug therapies to manage symptoms. Baclofen was used in 15 cases (60 percent), primarily in conjunction with gamma-aminobutyric acid type A agonists (12 of 15 cases) or as monotherapy during a phenibut taper (two of 15 cases). Two patients using baclofen monotherapy outpatient, after initial stabilization with multiple drug classes, reported adverse effects. One patient had a seizure and the other experienced recurrent withdrawal symptoms, returned to using phenibut, and was admitted to a hospital for withdrawal symptom management with benzodiazepines. This review is subject to several limitations. Due to the manual nature of article selection, it is possible relevant articles may not have been included. As the entire data set is comprised of case reports it may suffer from publications bias. Outcomes and meaningful conclusions from specific treatment strategies were rarely available because of the heterogeneous nature of case reports. It is possible those reporting only phenibut use were actually using multiple substances. The doses of phenibut a user believed they were taking may be different from what was present in the unregulated product. Phenibut withdrawal appears to have a range of severity. It is important to recognize that patients undergoing phenibut abstinence may have progressive symptom worsening during early withdrawal. All published cases of abrupt phenibut abstinence were admitted inpatients for symptom management. Benzodiazepines or barbiturates with adjunctive baclofen appear to be the most commonly used drugs for moderate to severe withdrawal. Outpatient management via slow phenibut tapers with or without adjunctive gamma-aminobutyric acid agonist therapy may be successful. However, there is no standard treatment, and consultation with experts (e.g., toxicologists, addiction specialists) experienced in managing withdrawal syndromes is recommended. Significant study is warranted to develop methods of triaging phenibut withdrawal (e.g., severity scoring, inpatient versus outpatient management) and creating optimal treatment regimens. [ABSTRACT FROM AUTHOR]

This article discusses the case of a 45-year-old male who was envenomated by his pet Trimeresurus insularis, a blue Indonesian pit viper. The patient presented to an emergency department in the United States and consultation with a poison center and medical toxicologist was obtained. Although Thai green pit viper antivenom is not approved by the US FDA, it was recommended based on in vitro data. The patient was transferred to another hospital to acquire the antivenom and received multiple doses, resulting in improvement in pain and swelling. Challenges in managing exotic snake envenomation in the US were highlighted, including the need for reimbursement to lending institutions and the regulatory requirements for using foreign antivenoms. Preemptive relationship development between poison centers, hospital pharmacies, IRBs, and venom lending facilities was suggested to navigate these challenges. [Extracted from the article]

This is the 40th Annual Report of America's Poison Centers National Poison Data System (NPDS). As of 1 January, 2022, all 55 of the nation's poison centers (PCs) uploaded case data automatically to NPDS. The upload interval was 4.72 [4.40, 9.27] (median [25%, 75%]) minutes, effectuating a near real-time national exposure and information database and surveillance system. We analyzed the case data tabulating specific indices from NPDS. The methodology was similar to that of previous years. Where changes were introduced, the differences are identified. Cases with medical outcomes of death were evaluated by a team of medical and clinical toxicologist reviewers using an ordinal scale of 1-6 to assess the Relative Contribution to Fatality (RCF) of the exposure. In 2022, 2,483,183 closed encounters were logged by NPDS: 2,064,875 human exposures, 50,381 animal exposures, 363,099 information requests, 4,790 human confirmed nonexposures, and 38 animal confirmed nonexposures. Total encounters showed a 12.9% decrease from 2021, and human exposure cases decreased by 0.771%, while health care facility (HCF) human exposure cases increased by 0.214%. All information requests decreased by 48.4%, medication identification (Drug ID) requests decreased by 21.2%, and medical information requests showed a 76.92% decrease, although these remain twice the median number before the COVID-19 pandemic. Drug Information requests showed a 52.4% decrease, due to declining COVID-19 vaccine calls to PCs but still comprised 5.55% of all information contacts. Human exposures with less serious outcomes have decreased 1.70% per year since 2008, while those with more serious outcomes (moderate, major or death) have increased 4.41% per year since 2000. Consistent with the previous year, the top 4 substance classes most frequently involved in all human exposures were analgesics (11.5%), household cleaning substances (7.23%), antidepressants (5.61%), and cosmetics/personal care products (5.23%). Antihistamines (4.81%) replaced sedatives/hypnotics/antipsychotics as the 5th substance class. As a class, analgesic exposures increased most rapidly, by 1,514 cases/year (3.26%/year) over the past 10 years for cases with more serious outcomes. The top 5 most common exposures in children age 5 years or less were household cleaning substances (10.3%), analgesics (9.54%), cosmetics/personal care products (9.49%), dietary supplements/herbals/homeopathic (6.65%), and foreign bodies/toys/miscellaneous (6.61%). NPDS documented 3,255 human exposures resulting in death; 2,622 (80.6%) of these were judged as related (RCF of 1-Undoubtedly responsible, 2-Probably responsible, or 3-Contributory). These data support the continued value of PC expertise and the need for specialized medical toxicology information to manage the increasing number of more serious exposures. Unintentional and intentional exposures continue to be a significant cause of morbidity and mortality in the US. The near real-time status of NPDS represents a national public health resource to collect and monitor US exposure cases and information requests. The continuing mission of NPDS is to provide a nationwide infrastructure for surveillance for all types of exposures (e.g., foreign body, infectious, venomous, chemical agent, or commercial product), and the identification and tracking of significant public health events. NPDS is a model system for the near real-time surveillance of national and global public health. [ABSTRACT FROM AUTHOR]

Management of patients with salicylate toxicity frequently requires urine alkalinization to enhance excretion of salicylate. One strategy for determining when to stop urine alkalinization is to wait for two consecutive serum salicylate concentrations to be less than 300 mg/L (2.17 mmol/L) and declining. When alkalinization of the urine ceases, a rebound in serum salicylate concentration can occur from tissue redistribution or delayed gastrointestinal absorption. Whether this can lead to rebound toxicity is not well understood. This was a single-center, retrospective review of cases with a primary ingestion of acetylsalicylic acid reported to the local poison center over a five-year period. Cases were excluded if the product was not listed as the primary ingestion or if there was no serum salicylate concentration documented after discontinuation of intravenous sodium bicarbonate infusion. The primary outcome was the incidence of serum salicylate rebound to a concentration greater than 300 mg/L (2.17 mmol/L) after discontinuation of intravenous sodium bicarbonate infusion. A total of 377 cases were included. Of these, eight (2.1%) had a serum salicylate concentration increase (rebound) after stopping the sodium bicarbonate infusion. All these cases were acute ingestions. Five of the eight cases had rebound serum salicylate concentrations that were greater than 300 mg/L (2.17 mmol/L). Of these five patients, only one reported recurrent symptoms (tinnitus). Prior to stopping urinary alkalinization, the last or the last two serum salicylate concentrations were less than 300 mg/L (2.17 mmol/L) in three and two cases, respectively. In patients with salicylate toxicity, the incidence of rebound in serum salicylate concentration after cessation of urine alkalinization, is low. Even if serum salicylate rebounds to supratherapeutic concentrations, symptoms are often absent or mild. Routine repeat serum salicylate concentrations after urine alkalinization is stopped may be unnecessary unless symptoms recrudesce. [ABSTRACT FROM AUTHOR]

The article addresses several issues regarding the treatment of phenibut withdrawal. Topics include the inaccuracy of statements about baclofen's safety in withdrawal management, the need for different treatment strategies for tapering versus abstinence, and concerns over the suggested dosing regimen for baclofen in comparison to phenibut.

This letter to the editor discusses a case involving the application of 17 lidocaine 4% patches to a patient's thigh. The patient did not experience any signs or symptoms of lidocaine toxicity, despite the large number of patches applied. However, it is important to note that this is a single case report and caution should be exercised when applying these findings to other exposure scenarios. The authors emphasize the need for further research and data on lidocaine patch absorption. [Extracted from the article]

This is the 39th Annual Report of America's Poison Centers' National Poison Data System (NPDS). As of 1 January, 2021, all 55 of the nation's poison centers (PCs) uploaded case data automatically to NPDS. The upload interval was 4.87 [4.38, 8.62] (median [25%, 75%]) minutes, effectuating a near real-time national exposure and information database and surveillance system. We analyzed the case data tabulating specific indices from NPDS. The methodology was similar to that of previous years. Where changes were introduced, the differences are identified. Cases with medical outcomes of death were evaluated by a team of medical and clinical toxicologist reviewers using an ordinal scale of 1-6 to assess the Relative Contribution to Fatality (RCF) of the exposure. In 2021, 2,851,166 closed encounters were logged by NPDS: 2,080,917 human exposures, 62,189 animal exposures, 703,086 information requests, 4,920 human confirmed nonexposures, and 54 animal confirmed nonexposures. Total encounters showed a 14.0% decrease from 2020, and human exposure cases decreased by 2.22%, while health care facility (HCF) human exposure cases increased by 7.20%. All information requests decreased by 37.0%, medication identification (Drug ID) requests decreased by 20.8%, and medical information requests showed a 61.1% decrease, although these remain about 13-fold higher than before the COVID-19 pandemic. Drug Information requests showed a 146% increase, reflecting COVID-19 vaccine calls to PCs. Human exposures with less serious outcomes have decreased 1.80% per year since 2008, while those with more serious outcomes (moderate, major or death) have increased 4.56% per year since 2000. Consistent with the previous year, the top 5 substance classes most frequently involved in all human exposures were analgesics (11.2%), household cleaning substances (7.49%), cosmetics/personal care products (5.88%), antidepressants (5.61%), and sedatives/hypnotics/antipsychotics (4.73%). As a class, antidepressant exposures increased most rapidly, by 1,663 cases/year (5.30%/year) over the past 10 years for cases with more serious outcomes. The top 5 most common exposures in children age 5 years or less were cosmetics/personal care products (10.8%), household cleaning substances (10.7%), analgesics (8.16%), dietary supplements/herbals/homeopathic (7.00%), and foreign bodies/toys/miscellaneous (6.51%). Drug identification requests comprised 3.64% of all information contacts. NPDS documented 4,497 human exposures resulting in death; 3,809 (84.7%) of these were judged as related (RCF of 1-Undoubtedly responsible, 2-Probably responsible, or 3-Contributory). These data support the continued value of PC expertise and the need for specialized medical toxicology information to manage more serious exposures. Unintentional and intentional exposures continue to be a significant cause of morbidity and mortality in the US. The near real-time status of NPDS represents a national public health resource to collect and monitor US exposure cases and information contacts. The continuing mission of NPDS is to provide a nationwide infrastructure for surveillance for all types of exposures (e.g., foreign body, infectious, venomous, chemical agent, or commercial product), and the identification and tracking of significant public health events. NPDS is a model system for the near real-time surveillance of national and global public health. [ABSTRACT FROM AUTHOR]

Dear Editor In recent years, much discussion surrounds higher dosing of intravenous (IV) n-acetylcysteine (NAC) in acetaminophen toxicity [[1]]. Commonly, this is described as a "three-bag" method for IV NAC administration, implying that, over each dosing interval a separate NAC dose is injected into its own bag of IV fluid and then given as a separate infusion. For example, a hospital may be instructed to administer the "one-bag" NAC regimen and logically conclude they should administer the three-bag regimen's daily dosing as a single, continuous infusion. [Extracted from the article]

Purpose Vasoactive medications are used during advanced cardiac life support (ACLS) to shunt oxygenated blood to vital organs and after return of spontaneous circulation (ROSC) to maintain hemodynamic goals. However, limited evidence exists to support vasoactive medication recommendations in such scenarios, and it is unknown how practices vary among emergency departments across the US. Methods A survey questionnaire (15 questions) was electronically distributed to emergency medicine pharmacists (EMPs) in the US through various professional listservs. Demographic information, American Heart Association ACLS algorithm medication use, and use of continuous vasopressor infusions and adjunct medications following ROSC were assessed and are reported descriptively. Results The survey was distributed to 764 EMPs, with a 23% response rate from a wide geographic distribution and 48% of respondents practicing in academic medical centers. Epinephrine dosing and administration during cardiac arrest were reported by most to be in accordance with ACLS cardiac arrest algorithms. Calcium, magnesium sulfate, and sodium bicarbonate were the most common adjunct intravenous medications given during cardiac arrest. Norepinephrine was the first-choice vasopressor (81%) for post-ROSC hypotension, while epinephrine was preferred less frequently (17%). Antibiotics and sodium bicarbonate were the most frequently administered post-ROSC adjunct medications. Conclusion This survey of a geographically diverse group of EMPs demonstrated high ACLS algorithm adherence for epinephrine during cardiac arrest with frequent additional administration of nonalgorithm medications. Sodium bicarbonate and calcium were the most frequently administered adjunct medications during cardiac arrest, while sodium bicarbonate and antibiotics were the most frequently used adjunct medications following ROSC. Norepinephrine was the most commonly used vasopressor following ROSC. [ABSTRACT FROM AUTHOR]