Effect of the first wave of COVID-19 on Poison Control Centre activities in 21 European countries: an EAPCCT initiative.

BACKGROUND: Public health emergencies often affect Poison Control Centre (PCC) operations. We examined possible effects of the coronavirus disease 2019 (COVID-19) pandemic on call volume, call characteristics, and workload in European PCCs. METHOD: All 65 individual European PCCs were requested to supply data on the number of calls and call characteristics (caller, age groups, reason and specific exposures) from March to June in 2018, 2019, and 2020 (Part 1). Number of calls with specific characteristics was normalised to all calls. Calls (N) and call characteristics (%) were compared between 2020 and 2018/2019 (average), within PCCs/countries and grouped. Correlation between call volume and COVID-19 cases per PCC/country was examined. All PCCs received a survey on workload (Part 2). Parts 1 and 2 were independent. RESULTS: For Part 1, 36 PCCs (21 countries) supplied 26 datasheets. PCCs in the UK and in France merged data and supplied one datasheet each with national data. Summed data showed an increase of 4.5% in call volume from 228.794 in 2018/2019 (average) to 239.170 in 2020 (p < 0.001). Within PCCs/countries, calls significantly increased for 54% of PCCs/countries (N = 14/26) and decreased for 19% (N = 5/26), three of which (N = 3/5) only serve medical professionals. Correlation between call volume and COVID-19 cases was (non-significant) positive (Rho >0.7) in 5/26 PCCs/countries (19%), and negative in 6/26 (23%). Call characteristics (median proportion of grouped data in 2018/2019 vs. 2020) changed: fewer medical professionals called (40 vs. 34%, p < 0.001), calls on intentional exposures decreased (20 vs. 17%, p < 0.012), as did calls on patients between 13 and 17 years (5 vs. 4%, p < 0.05). Calls on specific exposures increased; disinfectants from 1.9 to 5.2%, and cleaning products from 4.4 to 5.7% (p < 0.001). For Part 2, 38 PCCs (24 countries) filled the survey on workload (number/length of shifts and time on PCC duties), which increased in 23/38 PCCs (61%), while 10/38 (26%) worked with fewer employees. CONCLUSIONS: Obtaining aggregated European PCC data proved challenging but showed an increase in overall call volume and workload during the first COVID-19 wave. Call characteristics changed including fewer calls from professionals and more calls on specific exposures. Within single PCCs/countries a variety of effects was observed.

[Aconitine poisoning due to confusion of aconite leaves with lovage]. / Aconitinvergiftung durch eine Verwechslung von Eisenhutblättern mit Liebstöckel.

Due to a mix-up an older couple (69 years and 71 years) ate a meal with herbs from their garden that contained leaves of monkshood (Aconitum napellus). The monkshood plants grew close to the herbs in their garden. Both patients developed the typical symptoms of aconitine poisoning with paresthesia, hypotension and bradycardia. Over the course of time both developed cardiac arrhythmia with ventricular extrasystoles and required monitoring on the intensive care unit (ICU). The husband was more severely affected and needed catecholamines for successful treatment of hypotension (70/40 mmHg) and bradycardia (45 bpm). The toxicological analysis of the patients' serum taken 3.5 h after ingestion led to the detection of 1.8 ng/ml and 2.0 ng/ml aconitine, respectively. The patients were discharged in good general condition after 1 and 2 days, respectively. Monkshood (Aconitum napellus) is one of the most toxic native plants that can also be found in gardens due to its popularity as an ornamental plant. All parts of the plant contain toxic diterpenoid alkaloids, such as aconitine. Aconitine causes persistent activation of the fast voltage-gated sodium channels resulting in severe cardiac and neurological toxicity. Treatment of aconitine-induced ventricular arrhythmias is challenging as they are often refractory to electrical cardioversion and antiarrhythmic drugs.

[Trends in Abuse of Biogenic Drugs in Parts of Germany 2007-2013]. / Entwicklung des Missbrauchs psychotroper Pflanzen und Pilze in Deutschland ­ Interpretation der Zahlen aus 3 Giftinformationszentren für die Jahre 2007­2013.

AIM OF THE STUDY: Based on an abundance of information on the internet, psychotropic plants and mushrooms are of increasing relevance as legal and cheap alternatives to other illicit drugs. Due to the lack of a German database, the abuse of selected biogenic drugs using reported exposures to 3 German Poison Information Centres (PICs) was examined. METHODS: Information on abuse of biogenic drugs was collected from the German PICs in Berlin, Erfurt and Fribourg (2007-2013). RESULTS: 602 drug abuses were reported to the selected PICs. 52% reported consumption of tropane alkaloid-containing plants (Angel's trumpet, Thorn apple, Belladonna), 25% of psilocybin-containing mushrooms and 10% of nutmeg. Angel's trumpet was identified as the most abused plant. Consumers of tropane alkaloid-containing plants were mainly adolescents, whereas the majority of the abusers of psilocybin-containing mushrooms and nutmeg were rather young grown-ups and school children, respectively. A preponderance of moderate and severe effects (55%) could be noticed for exposures to tropane alkaloid-containing plants. More than 90% of suspected cases of tropane alkaloid-containing as well as psilocybin-containing plants abuse resulted in the treatment recommendation 'surveillance in hospital'. Mydriasis, hallucinations, tachycardia and agitation were the main symptoms after the abuse of biogenic drugs. CONCLUSIONS: The data from the PICs suggest abuse of biogenic drugs in parts of Germany. A decreasing trend is observed, probably caused by the competition with new synthetic designer drugs. The results underline the dominance of Angel's trumpet in the abuse of biogenic drugs and emphasize the importance of easy accessibility for the abuse of biogenic drugs. Unexpectedly, the number of nutmeg abuse cases increased during the investigated period.

Fatal doxepin intoxication--suicide or slow gradual intoxication?

The differentiation of intoxication courses is one of the most difficult challenges for forensic pathologists and toxicologists. The case of a 52-year-old female inpatient of a psychiatric clinic with multiple medications who died from doxepin intoxication is reported. Concentrations of doxepin metabolites and isomers, pharmacokinetic modelling and genotyping of the doxepin-metabolizing cytochrome P450 (CYP) enzymes led to the following conclusion: the lethal doxepin concentration of 2100 ng/mL was more likely to have been reached due to drug interactions and genetic peculiarities leading to a reduction of the metabolic capacity and not by an acute (suicidal) overdose.

Accidental clozapine intoxication in a toddler: clinical and pharmacokinetic lessons learnt.

WHAT IS KNOWN AND OBJECTIVE: Clozapine, a second generation antipsychotic which is relatively safe in overdose, has been used as an effective treatment alternative to traditional antipsychotics. The therapeutic use in children remains controversial. However, in accordance with the increasing prescription in adults, the accidental ingestion in childhood becomes more frequent. We report the youngest case of accidental clozapine ingestion. CASE SUMMARY: A 13-month-old girl presented with acute respiratory insufficiency and coma of unknown origin. The medical history, laboratory and radiological assessment did not link to aetiology until an almost spontaneous arousal after 22 h pointed towards intoxication. The initial standard drug screening using immunoassay had been negative. Hence, liquid chromatography mass spectrometry/mass spectrometry (LC-MS/MS) was performed, and clozapine was detected with a serum concentration of 736 ng/mL. WHAT IS NEW AND CONCLUSION: This case illustrates the diagnostic and forensic pitfalls in a coma of unknown origin due to the limits of toxicological screening immunoassays. LC-MS/MS analysis by an established method showed clozapine metabolites (norclozapine and clozapine-N-oxide) are detectable for longer period, especially in urine, when compared with clozapine. The clinical course is presented in unique correlation with plasma and urine concentrations of clozapine and its metabolites. The elimination pattern of clozapine in toddlers is similar to adults, and the toxic dose was found to be lower when compared with school-age children and adults.

[Poisoning by the autumn crocus plant]. / Verwechslungsgefahr im Frühjahr: Bärlauch und Herbstzeitlose. Warnen Sie lhre Patienten vor dem tödlichen Salat!

Confirmed cases of poisoning resulting from the ingestion of Colchicum autumnale in mistake for Allium ursinum were analysed retrospectively. The study included 32 patients between 27 and 90 years. The severity of the intoxication was graded on the basis of the poisoning severity score (PSS). All the patients developed diarrhea and/or vomiting after a latency period of between 2 and 24 h. All those patients with a latency of > 9 h suffered only mild poisoning. If the leaves were boiled before being eaten, 64% of the patients suffered moderate, severe or fatal poisoning; when the leaves were eaten raw, only 33%. It is presumed that heating may promote the liberation of colchicines from the plant. Eight of the nine patients with severe or fatal poisoning were older than 65 years. A possible cause of the more serious course in the elderly may be a decrease in renal clearance. In addition, a diminished sense of smell may allow the absence of the typical garlic smell and taste of Allium ursinum to go unrecognised.

Experiences of a poison center network with renal insufficiency in acetaminophen overdose: an analysis of 17 cases.

OBJECTIVE: Renal insufficiency is less common than liver failure in acetaminophen overdose but renal tubular damage occurs even in the absence of hepatotoxicity. Data published on this topic are rare consisting mostly of case reports or reports in a small number of patients. Presently, a larger number of patients with renal insufficiency associated with acetaminophen overdose should be analyzed using a multicenter approach. STUDY DESIGN: Retrospective analysis of patients with acetaminophen-related nephrotoxicity reported to a poison center network from 1995 to 2003. Renal insufficiency was defined as elevated serum creatinine of more than double of the normal range (>2.4 mg/dL [212 micromol/L]). Patients were classified into 4 groups (A: creatinine 2.4-5.0 mg/dL, B: creatinine>5.0 mg/dL requiring no dialysis, C: creatinine>5.0 mg/dL requiring dialysis, D: creatinine>5.0 mg/dL with fatal outcome). RESULTS: Seventeen patients were included (8 female, 9 male, average age 31.7 +/- 21.1 yrs) with 6 patients in group A (B: 7, C: 2, D: 2). In 5 patients renal insufficiency occurred without elevation of liver enzymes. Regarding possible risk factors 5 patients concomitantly ingested nephrotoxic substances, 4 presented with dehydration due to vomiting, 4 with chronic excessive dosing (overdose) of acetaminophen, 3 showed pre-existing renal insufficiency, 2 pre-existing liver disease and 2 died with multiple organ failure. CONCLUSIONS: Renal insufficiency in acetaminophen overdose mostly resolved without dialysis and occurred isolated without hepatotoxicity in less than one-third of the investigated patients. Conditions which might play a role as influencing factors for renal complications included concomitant ingestion of nephrotoxic drugs, dehydration, chronic excessive dosing (overdose) of acetaminophen, pre-existing renal or liver disease and multiple organ failure. Renal function should be monitored in acetaminophen overdose particularly in patients showing the latter comorbidity.