Severity of Deliberate Acute Baclofen Poisoning: A Nonconcurrent Cohort Study

Interest in high‐dose baclofen treatment for alcohol dependence has increased over the past few years. In the meantime, the rate of acute baclofen poisoning has increased and life‐threatening cases have been reported. Thus, severity of acute poisoning could lessen the benefit of baclofen treatment. Our aim was to evaluate the severity of acute baclofen poisoning independently of confounders and to assess whether severity is correlated with the reported ingested dose. We prospectively included consecutive patients with acute and deliberate baclofen overdose and compared them with gender and age‐matched patients from a retrospective cohort of common acute medicine self‐poisoning. The primary end‐point was the adjusted risk ratio of mechanical ventilation. We also analysed the lengths of mechanical ventilation and risks of aspiration pneumonitis and convulsions. We finally examined the correlation between the supposed reported ingested dose and the severity of poisoning. Fourteen baclofen‐poisoned patients were included and matched to 56 poisoned patients. Median age was 45y/o (40–58), and men comprised 43% of patients. In logistic regression, the adjusted risk ratio of mechanical ventilation was 7.9 (1.4–43.5; p = 0.02) for baclofen‐treated patients. Aspiration pneumonitis was more frequent in baclofen‐treated patients (29% versus 2%; p = 0.005), and the length of mechanical ventilation was significantly correlated with the reported ingested dose of baclofen (Spearman coefficients: 0.48; p < 0.001). Our results show that acute baclofen poisoning is more severe than other acute medicine overdoses, and severity seems to be correlated with the ingested dose of baclofen. These results raise some questions about the safety of high‐dose baclofen treatment for alcohol dependence.     

Levothyroxine Poisoning – Symptoms and Clinical Outcome

Levothyroxine (LT), T4, poisoning is rarely associated with a severe outcome. However, cases with significant complications have been reported. The aim of this study was to identify factors associated with symptoms of poisoning including late‐onset symptoms. All enquiries to the Danish Poison Information Centre (DPIC) concerning LT poisoning between March 2007 and September 2012 were reviewed and the following parameters were recorded: age, dose, time from ingestion, multiple drug intake and symptoms. To evaluate the frequency of late‐onset symptoms, a subgroup of patients without initial symptoms were contacted. A total of 181 patients were registered (112 children). Ingested LT dose ranged from 10 to 9000 mcg (median 275 mcg). A total of 29 of 181 (16%) patients were symptomatic at the time of enquiry, and there was no difference in ingested LT dose between asymptomatic and symptomatic patients, neither in children nor in adults (age 16–92 years) (p < 0.68 and p < 0.47, respectively). In total, 153 of 181 (85%) patients did not have symptoms of poisoning at the time of enquiry; however, in 9 of 21 (43%) patients, we were able to contact, late‐onset symptoms existed. In none of the cases, hospital contact was needed and there were no reports of long‐term sequelae. Acute LT poisoning often follows a benign course. The occurrence of symptoms appears not to be dose dependent. Late‐onset symptoms seem to be common. However, all symptoms resolved spontaneously without need of medical care.     

Overdose and adverse drug event experiences among adult patients in the emergency department

IntroductionOverdose is a leading cause of injury and death in the United States. Emergency Department (ED) patients have an elevated prevalence of substance use. This study describes overdose/adverse drug event experiences among adult ED patients to inform strategies to address overdose risk.MethodsPatients seeking care at a large ED in the city of Flint, Michigan participated in a computerized self-assessment during 2011–2013 (n = 4571). Overdose was assessed with a broad definition and included occurrences that could be considered adverse drug events. Among those with this type of experience, additional items assessed symptoms, outcomes, and intent.Results12% reported an overdose history. Of participants' most serious overdoses, 74% were without clear intent for self-harm, although this was true of only 61% of overdoses involving opiates or sedatives, and 52% had symptoms present that indicated that it was life-threatening. Binge drinking on a monthly basis (ORs = 1.4) was associated with a medically serious overdose compared to never having an overdose. Compared to no drug use in the last year, use of one drug was associated with an OR of 1.8, two drugs was associated with an OR of 5.8, three drugs was associated with an OR of 8.4, and four or more drugs was associated with an OR of 25.1 of having had a medically serious overdose (all p < 0.05).ConclusionsMost overdose experiences among ED patients were without clear intent of self-harm. The ED may be an appropriate setting for efforts to reduce overdose risk, especially among polysubstance users.     

A Regional Drug and Therapeutics Committee‐led Intervention to Reduce the Hospital Costs of Expensive HIV Drugs

In 2009, the regional Drug and Therapeutics Committee (DTC) began a series of meetings with lead specialists in infectious diseases. The role of the DTC was to engage clinicians and ensure commitment to prescribing the least expensive drugs among the clinically equivalent HAARTs (highly active antiretroviral therapy). DTC also led implementation of a national guideline. This study analyses the impact of this process on HAART consumption and expenditure. The HAART consumption and expenditure (2009–2013) was compared to forecasts produced by exponential smoothing (2004–2009). Abrupt switches between drug regimens coincided with the DTC‐led meetings. Overall, HAART consumption rose 16%, while price per defined daily dose (DDD) fell 11% and the 2013 expenditure decreased 23%. The consumption of drugs addressed by the guideline rose 48%. Still, the 2013 expenditure was 41.5 million DKK (5.5 million €) (27%) lower than expected, reflecting a fall in price per DDD that coincided with the intervention. The consumption of drugs not addressed by the guideline rose 8.3%, while price per DDD fell 8.5% and the 2013 expenditure was 26.8 million DKK (3.6 million €) (19%) lower than expected. Despite a steadily increasing consumption, significant cost savings followed this DTC‐led intervention. This multifaceted approach might be applicable to changing the prescribing of other expensive drug classes.     

Adverse Events Associated with Flumazenil Treatment for the Management of Suspected Benzodiazepine Intoxication – A Systematic Review with Meta‐Analyses of Randomised Trials

Flumazenil is used for the reversal of benzodiazepine overdose. Serious adverse events (SAEs) including seizures and cardiac arrhythmias have been reported in patients treated with flumazenil, and the clinical advantage of flumazenil treatment has been questioned. The objective was to assess the risk of (S)AEs associated with the use of flumazenil in patients with impaired consciousness due to known or suspected benzodiazepine overdose. Studies included in the meta‐analyses were identified by literature search in Medline, Cochrane Library and Embase using combinations of the words flumazenil, benzodiazepines, anti‐anxiety agents, poisoning, toxicity and overdose. Randomised clinical trials (RCTs) in verified or suspected benzodiazepine overdose patients comparing treatment with flumazenil versus placebo were included. Pre‐defined outcome measures were AEs, SAEs and mortality. Thirteen trials with a total of 994 randomised (990 evaluable) patients were included. AEs were significantly more common in the flumazenil group (138/498) compared with the placebo group (47/492) (risk ratio: 2.85; 95% confidence interval: 2.11–3.84; p < 0.00001). SAEs were also significantly more common in the flumazenil group compared with the placebo group (12/498 versus 2/492; risk ratio: 3.81; 95% CI: 1.28–11.39; p = 0.02). The most common AEs in the flumazenil group were agitation and gastrointestinal symptoms, whereas the most common SAEs were supraventricular arrhythmia and convulsions. No patients died during the blinded phase of the RCTs. The use of flumazenil in a population admitted at the emergency department with known or suspected benzodiazepine intoxication is associated with a significantly increased risk of (S)AEs compared with placebo. Flumazenil should not be used routinely, and the harms and benefits should be considered carefully in every patient.     

Deliberate Drug Poisoning with Slight Symptoms on Admission: Are there Predictive Factors for Intensive Care Unit Referral? A three‐year Retrospective Study

Deliberate drug poisoning leads to 1% of emergency department (ED) admissions. Even if most patients do not exhibit any significant complication, 5% need to be referred to an intensive care unit (ICU). Emergency physicians should distinguish between low‐ and high‐acuity poisoned patients at an early stage to avoid excess morbidity. Our aim was to identify ICU transfer factors in deliberately self‐poisoned patients without life‐threatening symptoms on admission. We performed a 3‐year retrospective observational study in a university hospital. Patients over 18 years of age with a diagnosis of deliberate drug poisoning were included. Clinical and toxicological data were analysed with univariate tests between groups (ED stay versus ICU transfer). Factors associated with ICU admission were then included in a logistic regression analysis. Two thousand five hundred and sixty‐five patients were included. 63.2% were women, and median age was 40 (28–49). 142 patients (5.5%) were transferred to ICU. Cardiac drugs [adjusted OR (aOR) = 19.81; 95% confidence interval (95% CI): 7.93–49.50], neuroleptics (aOR = 2.78; 95% CI: 1.55–4.97) and meprobamate (aOR = 2.71; 95% CI: 1.27–5.81) ingestions were significantly linked to ICU admission. A presumed toxic dose ingestion (aOR = 2.27; 95% CI: 1.28–4.02), number of ingested tablets (aOR = 1.01; 95% CI: 1.01–1.02 for each tablet) and delay between ingestion and ED arrival <2 hr (aOR = 2.85; 95%CI: 1.62–5.03) were also factors for ICU referral. The Glasgow Coma Scale was the only clinical feature associated with ICU admission (aOR = 1.57; 95% CI: 1.44–1.70 for each point loss). These results suggest that emergency physicians should pay particular attention to toxicological data on ED admission to distinguish between low‐ and high‐acuity self‐poisoned patients.     

Perceived Severity of and Susceptibility to Overdose Among Injection Drug Users: Relationships With Overdose History

Background: Overdose is relatively common among injection drug users (IDUs) yet little is known about how overdose-related health beliefs influence overdose experiences or risk reduction. Objectives: This study examines the association of perceived susceptibility to and perceived severity of nonfatal overdose with overdose history among IDUs attending needle exchange programs (NEPs) to inform prevention efforts. Methods: In 2009–2010, IDUs (N = 91) attending NEPs completed self-report surveys. Negative binomial regression modeled the association between demographics, age of injection initiation, length of time attending the NEP, perceived severity of overdose, and perceived susceptibility to overdose with lifetime history of nonfatal overdose. Results: Over half (55%) of participants reported lifetime overdose, with a mean of 2.9 overdoses. A multivariable negative binomial regression model revealed that younger current age, older age of first injection, non-Caucasian race, higher perceived severity of overdose, and lower perceived susceptibility to overdose were significantly correlated with fewer lifetime overdoses. Conclusions: Although our methodology precludes causal inferences, these findings are consistent with the hypothesis that perceived severity and perceived susceptibility are among several factors associated with IDUs' use of protective behaviors, which could influence the likelihood of overdose. Future prospective research to explore the impact of this and other health beliefs on risk behaviors and overdose could help improve the effectiveness of behavioral interventions.     

Overdose deaths following previous non‐fatal heroin overdose: Record linkage of ambulance attendance and death registry data

Introduction and Aims. Experiencing previous non‐fatal overdoses have been identified as a predictor of subsequent non‐fatal overdoses; however, few studies have investigated the association between previous non‐fatal overdose experiences and overdose mortality. We examined overdose mortality among injecting drug users who had previously been attended by an ambulance for a non‐fatal heroin overdose. Design and Methods. Using a retrospective cohort design, we linked data on non‐fatal heroin overdose cases obtained from ambulance attendance records in Melbourne, Australia over a 5‐year period (2000–2005) with a national death register. Results. 4884 people who were attended by ambulance for a non‐fatal heroin overdose were identified. One hundred and sixty‐four overdose deaths occurred among this cohort, with an average overdose mortality rate of 1.20 per 100 person‐years (95% CI, 1.03–1.40). Mortality rate decreased 10‐fold after 2000 coinciding with widely reported declines in heroin availability. Being male, of older age (>35 years) and having been attended multiple times for previous non‐fatal overdoses were associated with increased mortality risk. Discussion and Conclusions. As the first to show a direct association between non‐fatal overdose and subsequent overdose mortality, this study has important implications for the prevention of overdose mortality. This study also shows the profound effect of macro‐level heroin market dynamics on overdose mortality.[Stoové MA, Dietze PM, Jolley D. Overdose deaths following previous non‐fatal heroin overdose: Record linkage of ambulance attendance and death registry data. Drug Alcohol Rev 2009;28:347–352]     

Acute CO Poisoning is Associated with Impaired Fibrinolysis and Increased Thrombin Generation

Carbon monoxide (CO) poisoning is a leading cause of unintentional poisoning deaths in many countries. In ex vivo studies, CO released from carbon monoxide‐releasing molecules has been shown to attenuate fibrinolysis via increased alpha‐2‐antiplasmin activity. Hypofibrinolysis is associated with coronary ischaemia, which is also commonly observed in CO poisoning. We examined fibrin clot properties in acutely poisoned CO patients. Ex vivo plasma fibrin clot permeability, turbidimetry and efficiency of fibrinolysis were investigated in 48 patients and controls matched for age and sex. CO‐poisoned patients had 11.6% longer clot lysis time than the controls (p < 0.0001). No intergroup differences in clot permeability or turbidimetric variables were observed. Plasma tissue‐type plasminogen antigen (tPA), plasminogen activator inhibitor‐1 (PAI‐1) antigen and activity and F1.2 prothrombin fragments were higher in the patients than in the controls (all p < 0.0001). Plasma tPA activity was lower in the CO‐poisoned group. Multiple linear regression showed that a thrombin generation marker, F1.2, is the strongest predictor of clot lysis time, followed by PAI‐1 activity and carboxyhaemoglobin levels. In conclusion, this report is the first to demonstrate that acute CO poisoning in human beings is linked to increased thrombin generation and impaired fibrinolysis, which might contribute to ischaemic complications.     

Relationship between Serum Acetaminophen Concentration and N‐Acetylcysteine‐Induced Adverse Drug Reactions

Abstract: Intravenous N‐acetylcysteine is usually regarded as a safe antidote. However, during the infusion of the loading dose, different types of adverse drug reactions (ADR) may occur. The objective of this study was to investigate the relation between the incidence of different types of ADR and serum acetaminophen concentration in patients presenting to the hospital with acetaminophen overdose. This is a retrospective study of patients admitted to the hospital for acute acetaminophen overdose over a period of 5 years (1 January 2004 to 31 December 2008). Parametric and non‐parametric tests were used to test differences between groups depending on the normality of the data. SPSS 15 was used for data analysis. Of 305 patients with acetaminophen overdose, 146 (47.9%) were treated with intravenous N‐acetylcysteine and 139 (45.6%) were included in this study. Different types of ADR were observed in 94 (67.6%) patients. Low serum acetaminophen concentrations were significantly associated with cutaneous anaphylactoid reactions but not other types of ADR. Low serum acetaminophen concentration was significantly associated with flushing (p < 0.001), rash (p < 0.001) and pruritus (p < 0.001). However, there were no significant differences in serum acetaminophen concentrations between patients with and without the following ADR: gastrointestinal reactions (p = 0.77), respiratory reactions (p = 0.96), central nervous reactions (p = 0.82) and cardiovascular reactions (p = 0.37). In conclusion, low serum acetaminophen concentrations were associated with higher cutaneous anaphylactoid reactions. Such high serum acetaminophen concentrations may be protective against N‐acetylcysteine‐induced cutaneous ADR.     

Design,synthesis, and evaluation of novel diphenyl ether derivatives against drug‐susceptible and drug‐resistant strains of Mycobacterium tuberculosis

In our efforts to develop druggable diphenyl ethers as potential antitubercular agents, a series of novel diphenyl ether derivatives ( 5a – f , 6a – f ) were designed and synthesized. The representative compounds showed promising in vitro activity against drug‐susceptible, isoniazid‐resistant, and multidrug‐resistant strains of Mycobacterium tuberculosis with MIC values of 1.56 μg/ml ( 6b ), 6.25 μg/ml ( 6a–d ), and 3.125 μg/ml ( 6b–c ), respectively. All the synthesized compounds exhibited satisfactory safety profile (CC₅₀ > 300 μg/ml) against Vero and HepG2 cells. Reverse phase HPLC method was used to probe the physicochemical properties of the synthesized compounds. This series of compounds demonstrated comparatively low logP values. pKa values of representative compounds indicated that they were weak acids. Additionally, in vitro human liver microsomal stability assay confirmed that the synthesized compounds possessed acceptable stability under study conditions. The present study thus establishes compound 6b as the most promising antitubercular agent with acceptable drug‐likeness.     

Renal injury at first presentation as a predictor for poor outcome in severe paracetamol poisoning referred to a liver transplant unit

Background  Paracetamol poisoning remains a leading cause of morbidity and mortality. Identifying indices of poor prognosis at first presentation is key to both improving clinical care and determining targets for intervention. Renal failure is a feature of severe paracetamol poisoning. The aim of this study was to investigate the relationship between renal function (serum creatinine, Cr) at first hospital presentation and time of tertiary referral to outcomes in severe paracetamol poisoning. Methods  This was a retrospective cohort analysis of patients referred to the Scottish Liver Transplant Unit due to paracetamol poisoning between 1992 and 2004. The relation between degree of renal injury and outcomes, including worst prothrombin time, Kings College Hospital Criteria (KCHC) and death were examined. The effects of age, nature (single or multiple) and stated size of overdose, hepatic enzyme induction (gamma-glutamyl transpeptidase, GGT), degree of liver injury (aspartate aminotransferase, prothrombin time), blood pressure and renal injury were assessed. Results  Data from 522 patients were included. Renal impairment (Cr >120 mmol/l) was present in 48.8% of patients with liver injury at time of first presentation. Creatinine at first admission predicted poorer outcome in terms of worse prothrombin time, KCHC and death (p < 0.001). Associated risk factors for renal dysfunction included later presentation, staggered ingestion, increased age, hypotension and elevated GGT at first admission. Conclusions  Creatinine at first admission appears to be a predictor of poor outcome in paracetamol overdose. A better understanding of mechanisms involved in causing renal dysfunction may offer potential therapeutic targets for improving outcome in this common poisoning.     

Brief overdose education can significantly increase accurate recognition of opioid overdose among heroin users

BackgroundIn an effort to increase effective intervention following opioid overdose, the New York State Department of Health (NYSDOH) has implemented programs where bystanders are given brief education in recognizing the signs of opioid overdose and how to provide intervention, including the use of naloxone. The current study sought to assess the ability of NYSDOH training to increase accurate identification of opioid and non-opioid overdose, and naloxone use among heroin users.MethodsEighty-four participants completed a test on overdose knowledge comprised of 16 putative overdose scenarios. Forty-four individuals completed the questionnaire immediately prior to and following standard overdose prevention training. A control group (n = 40), who opted out of training, completed the questionnaire just once.ResultsOverdose training significantly increased participants’ ability to accurately identify opioid overdose (p < 0.05), and scenarios where naloxone administration was indicated (p < 0.05). Training did not alter recognition of non-opioid overdose or non-overdose situations where naloxone should not be administered.ConclusionsThe data indicate that overdose prevention training improves participants’ knowledge of opioid overdose and naloxone use, but naloxone may be administered in some situations where it is not warranted. Training curriculum could be improved by teaching individuals to recognize symptoms of non-opioid drug over-intoxication.     

Do Serotonin Reuptake Inhibitors Worsen Outcome of Patients Referred to the Emergency Department for Deliberate Multi‐drug Exposure?

Incidence of poisonings with serotonin reuptake inhibitors (SRIs) is growing. SRI toxicity is considered low, but its actual impact in multi‐drug poisonings remains unclear. Our objective was to evaluate the consequences of SRI exposure in patients referred to the emergency department (ED) for deliberate multi‐drug exposure. Patients admitted for multi‐drug exposure involving at least one SRI were matched with patients who did not ingest any SRI, according to age, gender, type of drug and ingested doses. Features of serotonin syndrome according to Sternbach's criteria and Hunter's serotonin toxicity criteria were evaluated from records. In 4 years, 148 SRI‐exposed patients were included and compared to 296 matched controls. The SRIs mainly involved were escitalopram (22%), venlafaxine (20%), fluoxetine (19%), citalopram (15%) and paroxetine (11%). Serotonin syndrome was diagnosed in one patient, but actually occurred in five SRI‐exposed patients based on the retrospective evaluation of records. Twenty patients (14%) exhibited one or more serotonin syndrome criteria. At least two of 11 of Sternbach's criteria and two of nine of Hunter's serotonin toxicity criteria were missing in each chart. Using a conditional logistic regression analysis, seizures (p = 0.04) and serotonin syndrome (p = 0.01 based on Sternbach's criteria and p = 0.004 based on Hunter's serotonin toxicity criteria) more frequently occurred in SRI‐exposed patients. Requirement for mechanical ventilation was significantly increased (p = 0.03), although admission to the intensive care unit was not. In multi‐drug‐poisoned patients admitted to the ED, exposure to SRIs significantly increases the risk of seizures and requirement for mechanically ventilation. Diagnosis of serotonin syndrome remains insufficient justifying improved training.     

The impact of current tobacco use on the outcome of paracetamol poisoning

Background : Tobacco smoke contains a number of substances that are capable of inducing cytochrome P450. Consequently, current tobacco use may enhance the hepatotoxicity from a paracetamol overdose by increasing the oxidative metabolism of paracetamol. Aim : To evaluate, by multivariate analysis, the effect of current tobacco use on the morbidity and mortality from paracetamol‐induced hepatotoxicity. Methods : A retrospective study was carried out on the basis of the hospital charts of 602 patients admitted with single‐dose paracetamol poisoning for whom information on current tobacco use was available. Results : In patients admitted with paracetamol poisoning, the rate of current daily tobacco use of 70% (424 of 602 patients) was considerably higher than the rate of 31% in the background population (chi‐squared test: P < 0.0001). Current tobacco use was an independent risk factor for the development of hepatic encephalopathy (odds ratio, 2.68; 95% confidence interval, 1.28–5.62) and mortality (odds ratio, 3.64; 95% confidence interval, 1.23–10.75). Current tobacco use was independently associated with high peak values of alanine transaminase and the international normalized ratio. Conclusions : Current tobacco use was very frequent in patients admitted with paracetamol poisoning. It was an independent risk factor of severe hepatotoxicity, acute liver failure and death following paracetamol overdose.     

Drug overdose mortality among stateside Puerto Ricans: Evidence of a health disparity

BackgroundThis study compared drug overdose mortality rates in Puerto Rican-heritage and Non-Hispanic (NH) White individuals in the United States (US), examining time trends and recent variation by age, sex, state of residence, and drugs involved in overdose.MethodsDeath certificate data from the National Center for Health Statistics, as well as American Community Survey population estimates, were used to calculate age-specific and age-adjusted drug overdose mortality rates for Puerto Rican-heritage and NH White residents of the 50 United States or District of Columbia (DC). Rates for 2018 were compared between Puerto Rican-heritage and NH White individuals, overall and by sex, age, state, and specific drug involved in overdose. Joinpoint Regression was used to examine trends in drug overdose mortality rates from 2009 to 2018.ResultsFrom 2009 to 2018, the age-adjusted drug overdose mortality rate in stateside Puerto Ricans doubled among women (from 6.0 to 12.5 per 100,000) and nearly tripled among men (from 15.3 to 45.2 per 100,000). In 2018, the age-adjusted drug overdose mortality rate was significantly higher in Puerto Rican-heritage than NH White individuals (28.7 vs. 26.2 per 100,000, respectively). The 2018 drug overdose mortality rate was highest among Puerto Rican-heritage men ages 45–54 (104.1 per 100,000).ConclusionFindings emphasize the necessity of policies, programs, and interventions to mitigate risk of fatal overdose in stateside Puerto Rican communities.     

Is the Measurement of Serum Formate Concentration Useful in the Diagnostics of Acute Methanol Poisoning? A Prospective Study of 38 Patients

The aim of this article was to study the role of serum formate (S‐formate) in diagnosing methanol poisoning. A prospective study was undertaken of 38 patients from the Czech methanol mass poisoning in 2012 – median age 51 [interquartile range (IQR) 37–62] years with confirmed methanol poisoning. S‐formate was measured enzymatically. The receiver operating characteristics (ROC) curve was used to examine the predictive ability of S‐formate. Asymptomatic patients had median S‐formate of 1.9 (IQR 1.5–2.4) mmol/L. The median S‐formate was 15.2 (IQR 13.9–17.6) mmol/L in symptomatic subjects with visual disturbances, 15.4 (12.1–18.0) mmol/L in subjects with dyspnoea and 15.7 (IQR 12.8–18.5) mmol/L in comatose patients. The differences in serum formate concentrations in symptomatic patients depending on clinical features were not significant (all p > 0.05). Patients with long‐term visual sequelae of poisoning had median S‐formate of 16.1 (IQR 14.3–19.9) mmol/L; with central nervous system (CNS) sequelae, patients had 15.9 (IQR 14.2–19.5) mmol/L. In lethal cases, the median S‐formate was 15.2 (IQR 13.8–15.9) mmol/L. The probability of a poor outcome (death or survival with sequelae) was higher than 90% in patients with S‐formate ≥17.5 mmol/L, S‐lactate ≥7.0 mmol/L and/or pH <6.87. The ROC analysis showed that the corresponding areas under the curve (AUC) were 0.64 (0.44–0.85 CI 95%) for S‐formate, 0.75 (0.56–0.93 CI 95%) for ‘S‐formate+S‐lactate’ and only 0.54 (0.38–0.69 CI 95%) for serum methanol, which is lower than for S‐formate (p < 0.05). The measurement of S‐formate is an important tool in the laboratory diagnostics and clinical management of acute methanol poisoning. S‐formate ≥3.7 mmol/L can lead to the first clinical signs of visual toxicity, indicating haemodialysis. S‐formate ≥11–12 mmol/L is associated with visual/CNS sequelae and a lethal outcome.     

Acute opiate overdose in Tehran: the forgotten role of opium

INTRODUCTION: The global epidemic of opiate use continues to spread and is an increasing burden especially in developing countries. Acute opiate overdose (AOO) is one of the most dramatic complications of drug abuse. The purpose of this study is to examine the epidemiology of acute opiate overdose in a poisoning center in Tehran. METHODS: In this cross-sectional survey, patients who attended the emergency room of Loghman-Hakim hospital - the only poisoning center in Tehran - and diagnosed with acute opiate overdose over a six month period were included. RESULTS: Overdose was more common among men (91.2%). The mean and standard deviation of age was 36.9+/-15. The most frequent opiate agent was opium (56.5%) followed by heroin. Opium was most commonly used by regular users, as a single agent and through ingestion. Benzodiazepines, antidepressants and alcohol were the most common agents consumed accompanied with opiates. The mortality rate was 8.8% which was not significantly different between cases of heroin and opium overdose. CONCLUSION: Opium was the major cause of overdose in our study. This result suggests that opium is not a harmless form of addiction although it is regarded as a thing of the past in many countries.