Clinical toxicology (Philadelphia, Pa.)最新文献

{"title":"Safety of acetylcysteine: a scoping review of iatrogenic overdose cases and their associated complications.","authors":"Maxwell B Baker, Joseph Young, Dhanesh D Binda, Erin Dienes, Joseph M Kennedy","doi":"10.1080/15563650.2026.2673132","DOIUrl":"10.1080/15563650.2026.2673132","url":null,"abstract":"<p><strong>Introduction: </strong>Acetylcysteine is the standard antidote for acetaminophen (paracetamol) toxicity and is widely considered safe when administered appropriately. However, an increasing number of case reports have documented serious adverse outcomes following its improper administration, including cerebral edema, hemolytic uremic syndrome, and death. As acetylcysteine is increasingly utilized for roles beyond acetaminophen overdose, its broader application introduces more opportunity for error. This review aims to systematically evaluate published cases of iatrogenic acetylcysteine overdose to characterize the risks, patterns of error, and outcomes associated with these events.</p><p><strong>Methods: </strong>We conducted a scoping review of peer-reviewed literature describing iatrogenic acetylcysteine overdose. Articles were identified using Covidence through a comprehensive search of MEDLINE and additional databases. Search terms and strategy were guided by medical subject heading analysis. Included cases reported dosing or infusion-related errors that led to clinical deterioration. Cases involving known side effects (e.g., anaphylactoid reactions without overdose) or abnormal lab values without clinical toxicity were excluded. Extracted variables included dosing protocol, route, type of error, timing of events, complications, and neurological outcomes utilizing the modified Rankin scale, when available.</p><p><strong>Results: </strong>A total of 16 reports met the inclusion criteria, with 14 describing toxicity from acetylcysteine overdose itself (analytic set) and two describing hyponatremia resulting from excess diluent volume. Among the 14 toxic overdose patients, 85.7% were female (mean age 18 years). Errors stemmed from the electronic medical record, pharmacy, provider, and nursing errors. Of the 14 reported acetylcysteine overdoses, 10 included sufficient information to analyze outcomes stratified by acetylcysteine exposure. Acetylcysteine exposure ≥1000 mg/kg was significantly associated with cerebral edema (<i>P</i> = 0.0476). Among the five patients who developed seizures, four (80%) had received ≥1000 mg/kg of acetylcysteine. However, this exposure was not significantly associated with seizure occurrence (<i>P</i> = 0.52). Death and severe disability, hemolytic uremic syndrome, and functional outcomes were not significantly different by dose threshold. Functional outcomes revealed a bimodal distribution: most patients either recovered fully or died, with a minority experiencing persistent deficits. Among the six fatal cases, four occurred in patients receiving three-bag regimens, and two occurred in those receiving two-bag protocols.</p><p><strong>Discussion: </strong>The significant association between acetylcysteine exposure ≥1000 mg/kg and cerebral edema underscores the importance of early recognition and intervention, particularly given the substantial lag period before clinical decline. Additionally, the predomina","PeriodicalId":520593,"journal":{"name":"Clinical toxicology (Philadelphia, Pa.)","volume":" ","pages":"636-647"},"PeriodicalIF":3.3,"publicationDate":"2026-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148348562","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Comment on: assessing unnecessary emergency department visits for poison exposures in pediatric patients less than six years old.","authors":"Adam Blumenberg","doi":"10.1080/15563650.2026.2678367","DOIUrl":"10.1080/15563650.2026.2678367","url":null,"abstract":"","PeriodicalId":520593,"journal":{"name":"Clinical toxicology (Philadelphia, Pa.)","volume":" ","pages":"741-742"},"PeriodicalIF":3.3,"publicationDate":"2026-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148255497","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A characterisation of one year of enhanced enquiry follow-up from a United Kingdom poison centre.","authors":"Pardeep S Jagpal, Hayley A Williams, Emma J Moyns, Rachael Day, Gurpreet S Jutley, Sally M Bradberry","doi":"10.1080/15563650.2026.2639572","DOIUrl":"10.1080/15563650.2026.2639572","url":null,"abstract":"<p><strong>Introduction: </strong>United Kingdom poison centres handle 40,000 telephone enquiries annually, and of these, follow-up is required for enquiries with a 'severe' Poisoning Severity Score or where requested by a clinical toxicologist. We sought to determine the resources required to expand the existing follow-up criteria in our centre to all cases with a Poisoning Severity Score ≥ 'minor'. We also sought to characterise the follow-up process including comparing the number of follow-up calls and length of time spent per case and assessing these against patient demographics. Our third objective was to survey the experiences of Specialists in Poisons Information during their undertaking of additional follow-up activities.</p><p><strong>Methods: </strong>We prospectively followed-up cases from hospitals between 1^st April 2024 and 31^st March 2025. Follow-up calls were made by Specialists in Poisons Information who documented the number of follow-up calls made and the total time spent on follow-up activities for each case. Data were analysed in Microsoft Excel^® and statistical tests performed in Python 3.10.</p><p><strong>Results: </strong>Our centre received 2,708 enquiries from hospitals, of which 1,352 met the inclusion criteria for enhanced follow-up. In total 3,845 outbound follow-up calls were placed lasting a total of 28,934 minutes, equating to 2.8 follow-ups lasting 21.4 minutes per case. There was a significant difference in both the median number of follow-up calls per case and the total time spent depending on the initial Poisoning Severity Score.</p><p><strong>Discussion: </strong>Enquiry follow-up is resource intensive, but our findings are broadly similar to those from other poison centres. Substantial improvement in the number of outcomes can be achieved but further work is required to understand whether resourcing pressures can be mitigated through other technologies such as artificial intelligence.</p><p><strong>Conclusions: </strong>Specialists in Poisons Information spend in excess of one hour per week each on follow-up activities. The amount of work varies in accordance with case severity, but additional outcome data is considered valuable.</p>","PeriodicalId":520593,"journal":{"name":"Clinical toxicology (Philadelphia, Pa.)","volume":" ","pages":"691-697"},"PeriodicalIF":3.3,"publicationDate":"2026-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147517996","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The venomous primate: unpacking the clinical manifestations of slow loris bites - an 11-year retrospective case series.","authors":"Achara Tongpoo, Kitisak Sanprasert","doi":"10.1080/15563650.2026.2634762","DOIUrl":"10.1080/15563650.2026.2634762","url":null,"abstract":"<p><strong>Introduction: </strong>The slow loris (<i>Nycticebus coucang</i>) is the only venomous primate, possessing a specialized defense mechanism capable of causing severe allergic reactions. Despite the potential for life-threatening envenomation, clinical data remain limited. This study aims to characterize the clinical manifestations and management of slow loris bites and grade allergic severity using the 2024 World Allergy Organization criteria.</p><p><strong>Methods: </strong>A retrospective case series was conducted on 28 patients presenting with slow loris bites at the Ramathibodi Poison Center. Medical records were reviewed for demographics, bite circumstances, clinical presentation, and treatment outcomes. The severity of systemic allergic reactions was graded according to the 2024 World Allergy Organization criteria.</p><p><strong>Results: </strong>A total of 28 patients were reviewed; fingers 13 (46%) and hands 4 (14%) were the most common bite sites. Significantly, 12 (43%) patients developed anaphylaxis, with eight (29%) experiencing angioedema and eight (29%) progressing to anaphylactic shock. World Allergy Organization severity grading indicated that four (14%) patients had grade 3 reactions, and eight (29%) had severe grade 4 reactions. Cutaneous symptoms were observed in 10 (36%) cases, while respiratory and gastrointestinal symptoms occurred in five (18%) and six (21%) cases, respectively. Wound infection was rare, occurring in only one (4%) patient.</p><p><strong>Conclusions: </strong>Slow loris envenomation is an immunological emergency defined by severe anaphylaxis rather than secondary infection. A significant diagnostic challenge is the occurrence of anaphylaxis presenting as isolated hypotension without the classic mucocutaneous signs. Consequently, management must prioritize hemodynamic monitoring and early epinephrine administration over wound care.</p>","PeriodicalId":520593,"journal":{"name":"Clinical toxicology (Philadelphia, Pa.)","volume":" ","pages":"657-660"},"PeriodicalIF":3.3,"publicationDate":"2026-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147439090","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Evidence-based reconstruction of medical toxicology fellowship orientation curriculum using a modified Delphi approach.","authors":"Lynne Rosenberg, Jacob Altholz, Joshua C Black, Jennie A Buchanan, Mark William Simon","doi":"10.1080/15563650.2026.2632180","DOIUrl":"10.1080/15563650.2026.2632180","url":null,"abstract":"<p><strong>Introduction: </strong>Currently, there are no evidence-based studies on orientation curriculum development for medical toxicology fellows. Fellows come from diverse training backgrounds yet are expected to manage a broad spectrum of toxicologic presentations in various practice environments. Standardized orientation curricula in other specialties have demonstrated improved comfort and knowledge of trainees. Our objective was to conduct an evidence-based reconstruction of orientation and study its impact on new fellows.</p><p><strong>Methods: </strong>We utilized a modified Delphi approach at a single toxicology fellowship. Participants were considered experts if they had graduated fellowship training or worked in fellowship administration. Second-year fellows were also included. A panel was convened to identify areas for improvement, followed by a survey to assess consensus using a Likert scale. The survey had four sections: core content, logistics, expectations, and wellness. Consensus was categorized as strong (≥75%), weak (50-74%), or non-consensus (<50%). A second panel resolved non-consensus items. After orientation was reconstructed, new fellows' knowledge and comfort was assessed with pre- and post-tests before and after orientation.</p><p><strong>Results: </strong>Twelve experts participated in the panel process, followed by eight in the second panel. Thirty toxins and toxicology concepts met consensus as important to cover during orientation. There was strong consensus to cover most logistical, expectation, and wellness topics. After reconstruction, the three new fellows showed improved medical knowledge, comfort, and policy familiarity.</p><p><strong>Discussion: </strong>The modified Delphi process highlighted topics most important to cover at the beginning of fellowship. Important toxins fell into two main categories: common exposures and rare exposures requiring emergent action. Adding logistic, expectation, and wellness topics improved fellow experience. This intervention employed concepts central to adult learning theory.</p><p><strong>Conclusions: </strong>Our study suggests there is consensus amongst expert toxicologists regarding essential topics during medical toxicology fellow orientation. This pilot data is a framework for developing an evidence-based, specialty-specific orientation curriculum.</p>","PeriodicalId":520593,"journal":{"name":"Clinical toxicology (Philadelphia, Pa.)","volume":" ","pages":"648-656"},"PeriodicalIF":3.3,"publicationDate":"2026-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147286947","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Assessing unnecessary emergency department visits for poison exposures in pediatric patients less than six years old.","authors":"Liam P McLoughlin, Howard A Greller, Mehruba A Parris, Christopher W Meaden, Christine Ramdin, Trevor Cerbini, Bruce Ruck, Diane P Calello","doi":"10.1080/15563650.2026.2654540","DOIUrl":"10.1080/15563650.2026.2654540","url":null,"abstract":"<p><strong>Introduction: </strong>We will investigate the medical necessity of pediatric emergency department presentations, specifically for emergency department poison cases where a poison control center was not contacted prior to presenting.</p><p><strong>Methods: </strong>A retrospective analysis of 348 poison control center cases involving patients aged < six, originating from a healthcare facility were evaluated. Toxicologists were presented with case summaries and were asked: \"would you send this patient to the emergency department?\" Evaluators answered on a 4-point Likert scale from \"definitely would not send\" to \"definitely would send.\" Reviewers had the opportunity to write in additional information that would be beneficial to deciding their disposition. To simulate the need to make a yes or no decision on whether to send, Likert scores were manipulated into a binomial score of 0/1. Binomial regression analysis and qualitative thematic analysis were completed.</p><p><strong>Results: </strong>Toxicologists found that 38% of patients definitely did not require emergency department evaluation, and 27% were unlikely to require it. The presence of clinical symptoms were significantly associated with increased concern by toxicologists. Qualitative analysis from reviewer free text case comments, demonstrated that understanding the situation surrounding the exposure (certainty, past medical history, etc. <i>n</i> = 26) and presence of specific symptoms in each case (fever, vomiting, etc. <i>n</i> = 25) were desired to better determine the need for an emergency department.</p><p><strong>Discussions: </strong>About 65% of cases were evaluated as not requiring emergency department evaluation. The presence of clinical symptoms is a key factor related to clinician level of concern. Further work should include finding ways to prevent these emergency department presentations.</p><p><strong>Conclusions: </strong>Many emergency department evaluations for poison exposure amongst children less than six years old are not medically required. Further work should focus on improving parental knowledge of poison centers and poison safety, while continuing to promote poison centers as accessible resources to the public.</p>","PeriodicalId":520593,"journal":{"name":"Clinical toxicology (Philadelphia, Pa.)","volume":" ","pages":"678-684"},"PeriodicalIF":3.3,"publicationDate":"2026-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147848886","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Author's reply to comment on \"We need a standardized North American acetylcysteine dosing regimen for the treatment of paracetamol (acetaminophen) poisoning\".","authors":"Milton Tenenbein","doi":"10.1080/15563650.2026.2673137","DOIUrl":"10.1080/15563650.2026.2673137","url":null,"abstract":"","PeriodicalId":520593,"journal":{"name":"Clinical toxicology (Philadelphia, Pa.)","volume":" ","pages":"739-740"},"PeriodicalIF":3.3,"publicationDate":"2026-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148255544","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Clinical outcomes of single-agent mifepristone exposures reported to US Poison Centers: a ten-year review of the National Poison Data System^® (2015-2024).","authors":"Ann M Arens, Abigail Olinde, Taft Knowles, Samantha C Lee","doi":"10.1080/15563650.2026.2642217","DOIUrl":"10.1080/15563650.2026.2642217","url":null,"abstract":"<p><strong>Introduction: </strong>Mifepristone is a 19-nor steroid that functions as a progesterone and glucocorticoid receptor antagonist with multiple uses approved by the United States Food and Drug Administration. Although its safety with therapeutic use is well established, data describing single-agent mifepristone toxicity is limited.</p><p><strong>Methods: </strong>This was a retrospective review of single-agent mifepristone exposures reported to the National Poison Data System^{^Ⓡ} from 1 January 2015, through 31 December 2024. Cases involving co-exposures, combination products, or unrelated outcomes were excluded. Demographic characteristics, exposure circumstances, clinical effects, management sites, therapies, and outcomes were analyzed using descriptive statistics.</p><p><strong>Results: </strong>Of 106 single-agent mifepristone exposures misoprostol identified, 77 patients met inclusion criteria. Patients were categorized as children ≤12 years old or adolescents/adults >12 years old. The mean patient age was 18.1 years (range 5 months-71 years), and 76.6% were female. Eight patients (10.3%) were pregnant. Most exposures were acute (93.5%), unintentional (64.9%), and occurred by oral ingestion (94.8%). The most common effects were nausea or vomiting (7.8%), abdominal pain (5.2%), and dizziness or vertigo (3.9%). The most common therapies were dilution or irrigation (13%), intravenous fluids (2.6%), steroids (2.6%), and antihistamines (2.6%). Two patients were admitted to non-critical care units, and there were no major effects or deaths. Among pregnant patients, no fetal deaths or significant maternal complications were reported.</p><p><strong>Discussion: </strong>Mifepristone exposures reported to United States poison centers in our study were uncommon and typically associated with mild, self-limited symptoms. No major effects, critical care admissions, or deaths were identified.</p><p><strong>Conclusion: </strong>These findings suggest that single-agent mifepristone exposures rarely result in major effects and generally follows a benign clinical course.</p>","PeriodicalId":520593,"journal":{"name":"Clinical toxicology (Philadelphia, Pa.)","volume":" ","pages":"698-704"},"PeriodicalIF":3.3,"publicationDate":"2026-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147535457","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Seeing is believing: a case of radiopaque lithium carbonate.","authors":"Nicholas Scaturo, Christopher Davidson, Eric Goldenberg","doi":"10.1080/15563650.2026.2662430","DOIUrl":"10.1080/15563650.2026.2662430","url":null,"abstract":"","PeriodicalId":520593,"journal":{"name":"Clinical toxicology (Philadelphia, Pa.)","volume":" ","pages":"735-736"},"PeriodicalIF":3.3,"publicationDate":"2026-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147966943","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Adsorption of lithium, rubidium, cesium, thallium, and lead onto activated charcoal: adsorption selectivity, kinetics, isotherms, and decontamination potential.","authors":"Decai Cao, Gen Ba, Zengzhen Wei, Jing Zhang, Beiyan Zhang, Jinsong Zhang, Xin Di, Zhengsheng Mao","doi":"10.1080/15563650.2026.2655386","DOIUrl":"10.1080/15563650.2026.2655386","url":null,"abstract":"<p><strong>Introduction: </strong>The adsorption capacity of activated charcoal was systematically evaluated for five metal ions, lead, thallium, cesium, rubidium and lithium, with particular emphasis on elucidating the underlying adsorption mechanisms and ion selectivity patterns.</p><p><strong>Methods: </strong>The surface structure of activated charcoal was characterized using Fourier transform infrared spectroscopy, X-ray photoelectron spectroscopy, and temperature-programmed desorption mass spectrometry to identify potential functional groups involved in the adsorption of metal ions. The concentration of metal ions was measured by inductively coupled plasma-mass spectrometer. The effects of adsorption time, pH, and ion concentration were systematically studied. Adsorption kinetics were fitted to the pseudo-first-order and pseudo-second-order models to elucidate the dominant mechanism, representing physisorption and chemisorption, respectively. Adsorption isotherms were fitted to the Langmuir and Freundlich models to evaluate the adsorption capacity and behavior of activated charcoal.</p><p><strong>Results: </strong>The surface of activated charcoal contains potential adsorption functional groups, including carboxyl, phenolic hydroxyl, carbonyl, and anhydride. The material exhibits adsorption of lead, thallium, cesium and rubidium ions, while showing no adsorption for lithium ions. Adsorption capacity increased with both pH (ranging from 2 to 6) and metal ion concentration. All adsorption processes followed the pseudo-second-order kinetic model, suggesting that chemisorption is the predominant adsorption mechanism. Adsorption isotherms showed lead, cesium and rubidium ions best fit the Langmuir model, while thallium followed the Freundlich model. Both Langmuir and Freundlich models indicated favorable adsorption under experimental conditions. The experimental adsorption capacity decreased in the order: lead (8.8 mg/g) > thallium (2.7 mg/g) > cesium (1.0 mg/g) > rubidium (0.7 mg/g) > lithium (0.0 mg/g).</p><p><strong>Discussion: </strong>This study found that the adsorption capacity of activated charcoal for different metal ions is influenced by factors such as pH and metal ion concentration. As pH increased, the adsorption efficiency improved, suggesting that the highly acidic environment in the stomach (pH ≈ 1.2) may limit its effectiveness in decontamination. Additionally, the study revealed that, under a chemisorption dominated mechanism, the adsorption capacity of activated charcoal follows a consistent pattern with the relative atomic masses of the five metal ions.</p><p><strong>Conclusions: </strong>This study systematically evaluates the adsorption of five metal ions by activated charcoal, revealing that adsorption capacity is influenced by pH, ion concentration, and atomic mass, with chemisorption as the dominant mechanism, providing valuable insights for its application in metal ion poisoning treatment.</p>","PeriodicalId":520593,"journal":{"name":"Clinical toxicology (Philadelphia, Pa.)","volume":" ","pages":"715-727"},"PeriodicalIF":3.3,"publicationDate":"2026-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147848177","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}