Alarming increase in poisonings from recreational nitrous oxide use after a change in EU-legislation, inquiries to the Dutch Poisons Information Center.

BACKGROUND: After the change in EU-legislation in 2014, recreational use of nitrous oxide (N2O) increased in the Netherlands from 2015 onwards. We studied the effect on N2O poisonings during an 11 year period. METHODS: A retrospective observational study was performed on the incidence rate of N2O poisonings, relative to all recreational drug poisonings reported to the Dutch Poisons Information Center (DPIC) from 2010-2020. Secondary outcomes were the frequency of heavy use, frequent use, co-exposures, and toxicity in 2019 and 2020. RESULTS: 433 N2O poisonings were included. The incidence rate increased exponentially from 0.12% in 2010 to 11% in 2020, with an average monthly rate of 3.8%. In 2019 and 2020, 79% of the patients indicated heavy use, frequent use or both, and 42% used from large cylinders. Chronic toxicity (signs of peripheral neuropathy) was reported in 38% of the patients. CONCLUSION: The rate of N2O poisonings increased alarmingly in the Netherlands. An increasing proportion of patients reported problematic heavy or frequent use, accompanied by chronic toxicity.

[Treatment of paracetamol intoxication: taking into consideration dosage, route of administration, and risk factors]. / Behandeling van intoxicatie met paracetamol.

- Paracetamol is the drug for which the Dutch Poisons Information Centre (DPIC) receives the most information requests.- The protocol for the treatment of single acute oral paracetamol intoxications is clear, however, ambiguity exists concerning the treatment of intoxications with repeated supratherapeutic doses of paracetamol.- Paracetamol intoxications with liquid preparations, extended-release tablets, exposure routes other than oral, and repeated supratherapeutic ingestions require a tailored approach.- An increased risk of liver damage due to paracetamol intoxication has to be taken into account for patients who consume excessive levels of alcohol, are malnourished or have a pre-existing liver condition.- The decision tree of the DPIC is a helpful tool to swiftly attain a risk assessment and treatment plan for most types of paracetamol intoxication.

[Anticholinergic syndrome caused by contaminated herbal tea; acting swiftly to identify the source]. / Anticholinerg syndroom door verontreinigde kruidenthee.

BACKGROUND: Despite good manufacturing practice and quality control, consumer products can become contaminated. In some cases, this can result in severe and life-threatening intoxication with potentially fatal consequences. CASE DESCRIPTION: A 27-year-old man and a 28-year-old pregnant woman presented to the Emergency Department with severe anticholinergic syndrome after using a marshmallow root (Althaea officinalis) herbal remedy, mixed into hot chocolate drink, to reduce symptoms of common cold. After a short stay in Intensive Care, the symptoms diminished and the patients could be released from hospital. The herbs were found to be contaminated with atropine, most probably derived from deadly nightshade (Atropa belladonna). Analyses of the contaminated product indicated that the patients were exposed to 20-200 mg atropine, while a dose of 2 mg is already considered mildly toxic. CONCLUSION: Consultation of the Dutch National Poisons Information Center resulted in rapid detection of the contamination; close collaboration with the Netherlands Food and Consumer Product Safety Authority and the manufacturer of the product allowed rapid identification of the source of contamination and facilitated the prevention of an epidemic.

[Intoxication with new psychoactive substances: drug unknown, but complications are still treatable]. / Intoxicatie met nieuwe psychoactieve stoffen.

Abuse of new psychoactive substances (NPS) and the number of patients presenting to the ER with intoxication are increasing. Treatment may at first sight seem complicated because of limited knowledge of the substance involved, but should be based on a general supportive approach recognising the relatively predictable spectrum of symptoms caused by adrenergic, serotonergic and dopaminergic stimulation. In this article, we discuss the vital elements of this approach and possible complications of NPS intoxication. This is illustrated by two 20-year-old male patients with NPS intoxication who presented to our ER as participants in a group intoxication. Patient A suffered from mild symptoms and tested positive for 4-iodo-2,5-dimethoxy-N-(2-methoxybenzyl)phenethylamine (2C-I-NBOMe) only. Patient B presented with agitated delirium and tested positive for both 2C-I-NBOMe and cocaine. While patient A was treated with benzodiazepines and rehydration, patient B required sedation, intubation and short-term ventilation.

[The effects of blue algae on health]. / Gezondheidseffecten van blauwalgen.

Cyanobacteria (blue algae) regularly cause recreational waters to become murky and smelly. Skin irritation and mild gastrointestinal disorders have regularly been reported following recreational activities in water suspected of being contaminated with cyanobacteria. The exact cause of these effects on health is not clear. Severe effects are not to be expected from recreational exposure to water contaminated with cyanobacteria. Cyanobacteria can produce hepatotoxins, neurotoxins, cytotoxins and irritants. In Brazil lethal intoxications have occurred due to the occurrence of toxins in drinking water and in dialysis fluid. The Dutch policy is based on the Commissie Integraal Waterbeheer (Commission Integral Water Management) guidelines for recreational waters. It is not clear to what extent the other cyanotoxins occur in the Netherlands. However, several genera ofcyanobacteria capable of producing these other cyanotoxins have been found in the Netherlands. For a good risk assessment in the Netherlands, more information is needed on the effects on health of cyanobacteria. There is also a need for more data on the prevalence of different cyanobacteria and toxins in Dutch recreational waters.