Clinical toxicology in Edinburgh, two centuries of progress.

The Scottish Poisons Information Bureau was established in Edinburgh in September 1963 and shortly afterwards one of the wards of the city's Royal Infirmary was designated a Regional Poisoning Treatment Centre. Both units were soon to be brought under one roof. To mark this 50th anniversary, we review how they built upon a history dating from the early 19th century and highlight their influence on current clinical toxicological practice and the delivery of poisons information. While many centres worldwide seek to improve the care of poisoned patients, the contribution of Edinburgh over the past 50 years has been notable.

Differences in treatment advice for common poisons by poisons centres--an international comparison.

OBJECTIVE: To investigate how poisons centres advise on management of common drug poisonings and compare advice on gut decontamination with the EAPCCT/AACT Position Statements. METHODS: An interactive questionnaire was sent to 14 poisons centres asking about working practices, "top 20" enquiries in 2002, and management of 4 specific drug poisonings. RESULTS: Replies were received from centres in 11 countries. Annual telephone enquiry numbers varied from 620 (Sri Lanka) to over 50,000 (Germany for 2000). Recommendations for gut decontamination for acetaminophen poisoning were: activated charcoal (AC) alone (5 centres); gastric lavage (GL) alone (1); AC and/or GL (3); AC, GL and/or ipecac (2). Only 40% (4/10) recommended AC and 50% (3/6) GL within 1 hour. Intervention doses for gut decontamination ranged from 100-200 mg/kg (nine centres) and for "high-risk" groups 75-100 mg/kg (3). Plasma concentration for N-acetylcysteine (NAC) treatment ranged from 150 mg/L (four centres) to 200 mg/L (6) at 4 hours. Results were similarly varied for three other common drug poisons (benzodiazepines, amitriptyline, and paroxetine). CONCLUSIONS: Most poisons centres have protocols that differ in terms of gut decontamination, timing, and intervention doses. Many centres recommend charcoal or gastric lavage after the 1-hour limit proposed in the Position Statements. There is scope for rationalization of approaches to the management of common poisons.

Lack of significant toxicity after mirtazapine overdose: a five-year review of cases admitted to a regional toxicology unit.

INTRODUCTION: Mirtazapine is a comparatively new antidepressant that selectively blocks central alpha2-adrenergic autoreceptors and postsynaptic 5-HT2 and 5-HT3 receptors, causing reduced neuronal norepinephrine and serotonin reuptake. The prevalence of mirtazapine prescribing has steadily risen; however, comparatively little information is available regarding the clinical features associated with mirtazapine overdose. AIMS: To characterize the toxic features that result from mirtazapine overdose. METHODS: We performed a retrospective case analysis of patients admitted to the Toxicology Unit of the Royal Infirmary of Edinburgh between January 2000 and December 2004 after stated mirtazapine overdose. Casenotes were examined for clinical, laboratory, and electrocardiographic safety data. RESULTS: There were 117 mirtazapine cases where the median (interquartile range) stated dose ingested was 450 mg (240-785 mg). Conscious level was reduced in 27.2% of patients and there was a higher incidence of tachycardia (30.4%) than predicted from normal reference range values (p < 0.001). There was no evidence of any other significant clinical, laboratory, or electrocardiographic abnormality. CONCLUSIONS: Severe toxic features could be attributed to other co-ingested drugs or alcohol. The adverse clinical effects attributable to mirtazapine overdose appeared mild and predictable. Mirtazapine overdose appears to be associated with fewer features of severe toxicity than previously reported for other antidepressants.

Web based information on clinical toxicology for the United Kingdom: uptake and utilization of TOXBASE in 2000.

AIMS: To examine the use and uptake of TOXBASE, an Internet database for point of care provision of poisons information in the United Kingdom during its first calendar year of web-based access. METHODS: Interrogation of the database software to examine: use by different types of user and geographical origin; profile of ingredient and product access; time of access to the system; profile of access to other parts of the database. RESULTS: Registered users of the system increased in the first full year of operation (1224 new users) and usage of the system increased to 111 410 sessions with 190 223 product monograph accesses in 2000. Major users were hospitals, in particular accident and emergency departments. NHS Direct, a public access information service staffed by nurses, also made increasing use of the system. Usage per head of population was highest in Northern Ireland and Scotland, and least in southern England. Ingredients accessed most frequently were similar in all four countries of the UK. Times of use of the system reflect clinical activity, with hospitals making many accesses during night-time hours. The most popular parts of the database other than poisons information were those dealing with childhood poisoning, information on decontamination procedures, teratology information and slang terms for drugs of abuse. CONCLUSIONS: This Internet system has been widely used in its first full year of operation. The provision of clinically relevant, up to date, information at the point of delivery of patient care is now possible using this approach. It has wide implications for the provision of other types of therapeutic information in clinical areas. Web-based technology represents an opportunity for clinical pharmacologists to provide therapeutic information for clinical colleagues at the bedside.