Publications by authors named "Diane P Calello"

67 Publications

Identification of a novel opioid, -piperidinyl etonitazene (etonitazepipne), in patients with suspected opioid overdose.

Clin Toxicol (Phila) 2022 Jun 16:1-3. Epub 2022 Jun 16.

American College of Medical Toxicology, Phoenix, AZ, USA.

Background: Novel opioids in the illicit drug supply, such as the "nitazene" group of synthetic opioids, present an ongoing public health problem due to high potency and respiratory depressant effects. We describe three patients in whom -piperidinyl etonitazene, a compound not previously reported in human exposure, was detected after suspected opioid overdose. Other substances that these patients tested for included fentanyl, cocaine, levamisole, phenacetin, benzoylecgonine, -fluorofentanyl, presumptive heroin (tested as 6-monoacetylmorphine (6-MAM), morphine, and codeine), and tramadol.

Methods: This is a case series of patients with acute opioid overdose enrolled in an ongoing multicenter prospective cohort study. Data collected included reported substance use, clinical course, naloxone dose and response, outcome, and analytes detected in biological samples.

Results: Between October 6, 2020 and October 31, 2021, 1006 patients were screened and 412 met inclusion criteria. Of these, three patients (age 33-55) tested positive for -piperidinyl etonitazene at one site in New Jersey over a period of three days in July 2021. Two patients reported the use of cocaine; one reported the use of heroin and alprazolam. All three patients received naloxone with improvement in their mental status (2 milligrams (mg) intranasally (IN); 8 mg IN; 0.08 mg intravenous (IV)). Two of three received subsequent doses for recurrence of opioid toxicity (0.4-0.6 mg IV). One patient was diagnosed with pneumonia and admitted to the intensive care unit, one was discharged from the Emergency Department (ED), and one used additional drug while in the ED and required admission for a naloxone infusion. None developed organ damage or sequelae.

Conclusion: These cases represent a local outbreak of a novel "nitazene" opioid. Public health toxicosurveillance should incorporate routine testing of this emerging class of synthetic compounds in the illicit drug supply.
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http://dx.doi.org/10.1080/15563650.2022.2084406DOI Listing
June 2022

Found Down: Approach to the Patient with an Unknown Poisoning.

Emerg Med Clin North Am 2022 May 5;40(2):193-222. Epub 2022 Apr 5.

Department of Emergency Medicine, Division of Medical Toxicology, Rutgers New Jersey School of Medicine, Newark, NJ, USA.

Approximately 30% of poison exposures reported to centers each year are either referred to or initiated within a health care facility. Among these exposures, undifferentiated poisoned patients are among the most challenging cases faced in the emergency department. Airway, breathing, circulation (ABCs) is central to the management of unknown poisoned patient. After initial stabilization, taking a systematic approach presented here may be beneficial to the clinician. This includes considering key additional history, a possible toxidrome, and data in the form of vital signs, physical examination, laboratory analysis, ECG, and imaging. After which a tailored approach to supportive care, decontamination, possible antidotes, and enhanced elimination techniques will improve outcomes.
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http://dx.doi.org/10.1016/j.emc.2022.01.011DOI Listing
May 2022

More on Carbon Monoxide Poisoning during Major U.S. Power Outages.

N Engl J Med 2022 04;386(14):1386-1387

Children's Hospital of Philadelphia, Philadelphia, PA.

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http://dx.doi.org/10.1056/NEJMc2201981DOI Listing
April 2022

Benzodiazepine and Stimulant Prescriptions Before Overdose in Youth.

Pediatrics 2022 04;149(4)

Columbia University Irving Medical Center, New York State Psychiatric Institute, New York, New York.

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http://dx.doi.org/10.1542/peds.2021-055226DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9097826PMC
April 2022

Should the Dosage Cap Be Used in Patients Greater than 100 kg Receiving N-acetylcysteine for Acetaminophen Toxicity?

J Med Toxicol 2022 01 10;18(1):65-66. Epub 2022 Jan 10.

Maryland Poison Center, University of Maryland School of Pharmacy, Baltimore, MD, USA.

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http://dx.doi.org/10.1007/s13181-021-00871-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8758859PMC
January 2022

Extracorporeal Treatment for Gabapentin and Pregabalin Poisoning: Systematic Review and Recommendations From the EXTRIP Workgroup.

Am J Kidney Dis 2022 01 17;79(1):88-104. Epub 2021 Nov 17.

Research Center, CIUSSS du Nord-de-l'île-de-Montréal, Hôpital du Sacré-Coeur de Montréal, University of Montreal, Montreal, Quebec, Canada. Electronic address:

Toxicity from gabapentin and pregabalin overdose is commonly encountered. Treatment is supportive, and the use of extracorporeal treatments (ECTRs) is controversial. The EXTRIP workgroup conducted systematic reviews of the literature and summarized findings following published methods. Thirty-three articles (30 patient reports and 3 pharmacokinetic studies) met the inclusion criteria. High gabapentinoid extracorporeal clearance (>150mL/min) and short elimination half-life (<5 hours) were reported with hemodialysis. The workgroup assessed gabapentin and pregabalin as "dialyzable" for patients with decreased kidney function (quality of the evidence grade as A and B, respectively). Limited clinical data were available (24 patients with gabapentin toxicity and 7 with pregabalin toxicity received ECTR). Severe toxicity, mortality, and sequelae were rare in cases receiving ECTR and in historical controls receiving standard care alone. No clear clinical benefit from ECTR could be identified although major knowledge gaps were acknowledged, as well as costs and harms of ECTR. The EXTRIP workgroup suggests against performing ECTR in addition to standard care rather than standard care alone (weak recommendation, very low quality of evidence) for gabapentinoid poisoning in patients with normal kidney function. If decreased kidney function and coma requiring mechanical ventilation are present, the workgroup suggests performing ECTR in addition to standard care (weak recommendation, very low quality of evidence).
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http://dx.doi.org/10.1053/j.ajkd.2021.06.027DOI Listing
January 2022

Acute coronary syndrome and transient global amnesia with sumatriptan.

Am J Emerg Med 2022 Mar 11;53:283.e1-283.e3. Epub 2021 Sep 11.

Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA; New Jersey Poison Information and Education System, Newark, NJ, USA. Electronic address:

Triptans are potent serotoninergic vasoconstrictors. They are generally avoided in elderly patients age greater than 65 or in patients with a history of CAD. Although there are reported cases of Acute Coronary Syndrome (ACS) or Transient Global Amnesia (TGA) in patients after ingesting therapeutic doses of triptan or dihydroergotamine, this is the first case report, up to our knowledge, of a patient, who had no previous cardiac history, that was diagnosed with both ACS and TGA. A 59-year-old woman with a long-standing history of migraine, gastroesophageal reflux disease, and hypothyroidism, presented to the Emergency Department (ED) complaining of amnesia, chest pain, and left arm numbness after ingesting a single dose of oral sumatriptan approximately 1-2 h prior to arrival. She had no recollection of the events that occurred after taking sumatriptan. No acute laboratory abnormalities were found except for an elevated troponin, which continued to trend upwards. Her EKG had no ST-T wave abnormalities. She was diagnosed with Acute Coronary Syndrome (ACS), non-ST elevation MI. She had a negative noncontrast CT head. Neurology was consulted for her amnesia and diagnosed her with Transient Global Amnesia (TGA). They recommended discontinuing sumatriptan and beginning topiramate as a prophylactic therapy. There is an increasing number of reports delineating sumatriptan's adverse effects. Emergency medicine physicians should promptly recognize the toxic effects and adverse reactions from triptans. Sumatriptan-induced vasoconstriction may lead to cardiac and cerebral ischemic events.
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http://dx.doi.org/10.1016/j.ajem.2021.09.019DOI Listing
March 2022

Illicit drug packet ingestion and the ASGE clinical guideline on removal of foreign bodies.

Gastrointest Endosc 2021 07;94(1):205

Department of Emergency Medicine, New Jersey Poison Information and Education System, Rutgers New Jersey Medical School, Newark, New Jersey, USA.

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http://dx.doi.org/10.1016/j.gie.2020.12.052DOI Listing
July 2021

The Poison Center as a pandemic response: establishment and characteristics of a COVID-19 hotline through the New Jersey Poison Center.

Clin Toxicol (Phila) 2021 12 31;59(12):1228-1233. Epub 2021 Mar 31.

Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA.

Background: Poison Centers are uniquely positioned to respond to an unprecedented public health threat such as the COVID-19 pandemic, as fully operational 24-h hotlines already staffed with healthcare professionals.

Methods: On January 27, 2020 the New Jersey Poison Information and Education System (NJPIES) agreed to operate the New Jersey Coronavirus Hotline. Call patterns, subject matter, and staffing and infrastructure strategies that were implemented to meet the demand are described. In addition, a sample of 1500 individual calls were collected and analyzed in an endeavor to describe call times, call days, area from which the call originated, callers to the hotline, primary language of the caller, and why a call was placed to the hotline. Binomial regression analysis was utilized in an attempt to identify significant patterns.

Results: Since the inception of the hotline through October 31, NJPIES responded to 57,579 calls for COVID-19 information. Most calls (68.7%) were regarding testing for COVID-19 and for general questions/symptoms. Call types varied when they were analyzed by time of day with calls for general questions/symptoms and where to get tested for COVID-19 showing a significant association for the early morning hours, how to obtain test results being significantly associated with the afternoon hours, and how to renew or obtain a medical license showing a significant association to the evening hours. We additionally noted that specific call types became significant when analyzed on a week-to-week basis and as specific events, like the enactment of the CARES Act of 2020, occurred.

Conclusion: Although not the traditional role of a regional Poison Control Center, pandemic response synergizes with the workflow of this hotline because the infrastructure, staffing, and healthcare expertise are already present. Poison centers can rapidly adapt through scaling and process change to meet the needs of the public during times of public health threats.
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http://dx.doi.org/10.1080/15563650.2021.1905163DOI Listing
December 2021

Carbon tetrachloride poisoning from an antique fire extinguisher.

Am J Emerg Med 2020 10 24;38(10):2139-2141. Epub 2020 Jul 24.

Rutgers New Jersey Medical School, Newark, NJ, United States of America; New Jersey Poison Information and Education System, Newark, NJ, United States of America.

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http://dx.doi.org/10.1016/j.ajem.2020.07.052DOI Listing
October 2020

The Toxicology Investigators Consortium Case Registry-the 2019 Annual Report.

J Med Toxicol 2020 10 1;16(4):361-387. Epub 2020 Oct 1.

University of Colorado School of Medicine, 13001 E 17th Pl, Aurora, CO, 80045, USA.

The Toxicology Investigators Consortium (ToxIC) Registry was established by the American College of Medical Toxicology (ACMT) in 2010. The Registry collects data from participating sites with the agreement that all bedside medical toxicology consultation will be entered. This tenth annual report summarizes the Registry's 2019 data and activity with its additional 7177 cases. Cases were identified for inclusion in this report by a query of the ToxIC database for any case entered from 1 January to 31 December 2019. Detailed data was collected from these cases and aggregated to provide information which included demographics, reason for medical toxicology evaluation, agent and agent class, clinical signs and symptoms, treatments and antidotes administered, mortality, and whether life support was withdrawn. 50.7% of cases were female, 48.5% were male, and 0.8% were transgender. Non-opioid analgesics was the most commonly reported agent class, followed by opioid and antidepressant classes. Acetaminophen was once again the most common agent reported. There were 91 fatalities, comprising 1.3% of all Registry cases. Major trends in demographics and exposure characteristics remained similar to past years' reports. Sub-analyses were conducted to describe exposures in cases of self-harm, gender differences in substance use disorder, and trends in addiction medicine and pain management consultations.
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http://dx.doi.org/10.1007/s13181-020-00810-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7554287PMC
October 2020

Emergency department patients' perceptions of the efficacy and safety of opioid analgesics.

J Opioid Manag 2020 Jul/Aug;16(4):239-246

Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, New Jersey.

Introduction: Emergency department (ED) providers are on the forefront of the prescription drug crisis and understand-ing patient's perceptions of opioids may allow physicians to better address misconceptions. The aim was to determine the perceptions of ED patients regarding the efficacy and safety of opioid analgesics.

Methods: Cross-sectional study of a convenience sample of adults at a single urban academic ED. Patients completed a tablet-based survey regarding the efficacy and safety of opioid analgesics.

Results: Of the 715 subjects, the sample was predominantly black (80.4 percent), female (59.2 percent), and aged 18-59 years (76.8 percent). The majority (70.1 percent) of respondents reported pain as the reason for visit. Seventy-two percent had previously taken an opioid primarily for acute pain, found them effective for pain (88.2 percent), and would be willing to do so again (62.7 percent). Adverse effects made patients less likely to use them again (OR 0.703, [0.659-0.751]). Gender and age did not affect perceptions of efficacy and safety, but certain racial groups did (OR 1.08, [1.02 to 1.14], p < 0.05). Knowing someone who used opioids in a nonmedical manner did not impact willingness to use opioids. Many (54 percent) believed opioids to be as safe as nonopioid alternatives. The majority (78 percent) consid-ered prescription opioid abuse a public health problem, however underestimated the number of annual opioid-related deaths.

Conclusion: The majority of ED patients had used opioids and considered the prescription drug crisis a public health problem. Through personal use or media coverage, the majority of participants considered opioids safe, even compared to nonopioid alternatives. Better understanding these viewpoints may improve patient-physician communication about analgesic treatment.
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http://dx.doi.org/10.5055/jom.2020.0577DOI Listing
October 2020

ACMT Position Statement: Limiting Harms of Vaping and E-cigarette Use.

J Med Toxicol 2021 01 29;17(1):87-90. Epub 2020 Jun 29.

Johns Hopkins University School of Medicine, Baltimore, MD, USA.

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http://dx.doi.org/10.1007/s13181-020-00791-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7785620PMC
January 2021

Opioid-Associated Hearing Loss: A 20-Year Review from the New Jersey Poison Center.

J Med Toxicol 2020 10 28;16(4):416-422. Epub 2020 May 28.

New Jersey Poison Information and Education System, Newark, NJ, USA.

Background: Opioid-associated ototoxicity is a known complication of opioid exposure, although the mechanism remains unclear. While historically most closely linked to heroin and oxycodone, evolving reports suggest that it may be a class effect of opioids. However, the evidence is limited to case reports.

Methods: A retrospective review of the New Jersey Poison Center records (ToxiCALL®) identified cases that included both hearing loss and recent opioid exposure between January 1, 1999, and September 21, 2018.

Results: Forty-one cases were identified, mean age 29.4 years, 51% (n = 21) were male. Reported heroin exposures comprised 51% (n = 22), 18 of which were heroin alone. The next most commonly cited opioids were oxycodone (n = 7), methadone, (n = 4), and tramadol (n = 3). Hearing loss was described as tinnitus in 24% of cases, hypoacusis in 37% of cases, deafness in 29% of cases, and mixed tinnitus/hypoacusis in 10% of cases. Only 34% (n = 14) of cases were associated with a potential hypoxic event. Of the cases that documented resolution data, 21% (n = 4 of 19) reported no improvement at time of hospital discharge.

Discussion: Opioid-associated ototoxicity appears to be a hypoxia-independent adverse effect since most of the reported cases did not involve a known contributory hypoxic event. It occurs with a wide array of opioids, which supports an opioid receptor-mediated mechanism. The ototoxic effect may be self-limited in many patients.

Conclusion: Opioid-associated ototoxicity was most commonly associated with heroin exposure and appeared independent of hypoxic events. Further investigation that clarifies the risk factors and long-term outcomes is needed.
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http://dx.doi.org/10.1007/s13181-020-00785-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7554281PMC
October 2020

Cleaning and Disinfectant Chemical Exposures and Temporal Associations with COVID-19 - National Poison Data System, United States, January 1, 2020-March 31, 2020.

MMWR Morb Mortal Wkly Rep 2020 Apr 24;69(16):496-498. Epub 2020 Apr 24.

On January 19, 2020, the state of Washington reported the first U.S. laboratory-confirmed case of coronavirus disease 2019 (COVID-19) caused by infection with SARS-CoV-2 (1). As of April 19, a total of 720,630 COVID-19 cases and 37,202 associated deaths* had been reported to CDC from all 50 states, the District of Columbia, and four U.S. territories (2). CDC recommends, with precautions, the proper cleaning and disinfection of high-touch surfaces to help mitigate the transmission of SARS-CoV-2 (3). To assess whether there might be a possible association between COVID-19 cleaning recommendations from public health agencies and the media and the number of chemical exposures reported to the National Poison Data System (NPDS), CDC and the American Association of Poison Control Centers surveillance team compared the number of exposures reported for the period January-March 2020 with the number of reports during the same 3-month period in 2018 and 2019. Fifty-five poison centers in the United States provide free, 24-hour professional advice and medical management information regarding exposures to poisons, chemicals, drugs, and medications. Call data from poison centers are uploaded in near real-time to NPDS. During January-March 2020, poison centers received 45,550 exposure calls related to cleaners (28,158) and disinfectants (17,392), representing overall increases of 20.4% and 16.4% from January-March 2019 (37,822) and January-March 2018 (39,122), respectively. Although NPDS data do not provide information showing a definite link between exposures and COVID-19 cleaning efforts, there appears to be a clear temporal association with increased use of these products.
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http://dx.doi.org/10.15585/mmwr.mm6916e1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7188411PMC
April 2020

Single-Agent Bupropion Exposures: Clinical Characteristics and an Atypical Cause of Serotonin Toxicity.

J Med Toxicol 2020 01 10;16(1):12-16. Epub 2019 Dec 10.

Emory University School of Medicine, Atlanta, GA, USA.

Introduction: Bupropion is the only Food and Drug Administration-approved synthetic cathinone. It increases the release of norepinephrine in the locus coeruleus and dorsal raphe nucleus, causing an increase in the frequency of serotonergic neuron firing. The diagnosis of serotonin toxicity (ST) from bupropion poisoning is controversial due to the lack of direct serotonergic activity. Nonetheless, there is one documented report of ST after single-agent bupropion overdose and multiple reports describing polypharmacy overdoses where bupropion may have contributed to ST.

Methods: This is a retrospective analysis of data collected by the Toxicology Investigators Consortium (ToxIC), a prospective multi-center toxico-surveillance and research network registry, from 2014 to 2017. Cases were identified if ST was a clinical effect and bupropion was the single agent listed. Data is presented descriptively.

Results: Of the 266 recorded single bupropion overdoses, the most common symptoms were seizures (47.1%), tachycardia (greater than 140 bpm) (33.9%), agitation (31.7%), toxic psychosis (20.4%), and myoclonus/tremor/hyperreflexia (19%). Benzodiazepines were the most common therapy (69.2%). Thirteen patients (5.9%) were diagnosed with ST by a medical toxicologist.

Conclusion: Bupropion overdose is primarily associated with seizures, tachycardia, and agitation; bupropion may be an atypical cause of serotonin toxicity.
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http://dx.doi.org/10.1007/s13181-019-00749-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6942117PMC
January 2020

Loperamide toxicity: recommendations for patient monitoring and management.

Clin Toxicol (Phila) 2020 05 4;58(5):355-359. Epub 2019 Nov 4.

Department of Emergency Medicine, Upstate Medical University, Upstate New York Poison Center, Syracuse, NY, USA.

This position statement is a collaborative effort by the American Academy of Clinical Toxicology (AACT) and the American Association of Poison Control Centers (AAPCC) and has been endorsed by the American College of Medical Toxicology (ACMT). The position statement describes loperamide misuse, proposed mechanisms of toxicity, adverse clinical effects, and recommendations for the acute monitoring and management of patients with loperamide toxicity. Use of high-dose loperamide for its euphoric effects and to self-treat opioid use disorder (in place of evidence-based therapies, like buprenorphine or methadone), is increasing. Despite reports in the medical literature and lay press, many remain unaware of high-dose loperamide use and how to manage patients with loperamide-associated toxicities. Providers in Emergency Medicine; Prehospital; Intensive Care; Internal Medicine; Primary Care; Gastroenterology; Addiction Medicine; Pharmacy.
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http://dx.doi.org/10.1080/15563650.2019.1681443DOI Listing
May 2020

The Toxicology Investigators Consortium Case Registry-the 2018 Annual Report.

J Med Toxicol 2019 10 22;15(4):228-254. Epub 2019 Oct 22.

University of Colorado School of Medicine, 13001 E 17th Pl, Aurora, CO, 80045, USA.

The Toxicology Investigators Consortium (ToxIC) Registry was established by the American College of Medical Toxicology (ACMT) in 2010. The Registry collects data from participating sites with the agreement that all bedside medical toxicology consultation will be entered. The objective of this ninth annual report is to summarize the Registry's 2018 data and activity with its additional 7043 cases. Cases were identified for inclusion in this report by a query of the ToxIC database for any case entered from 1 January to 31 December 2018. Detailed data was collected from these cases and aggregated to provide information which included demographics, reason for medical toxicology evaluation, agent and agent class, clinical signs and symptoms, treatments and antidotes administered, mortality, and whether life support was withdrawn. A total of 51.5% of cases were female, 48% were male, and 0.6% transgender. Non-opioid analgesics were the most commonly reported agent class, followed by antidepressants and opioids. Acetaminophen was once again the most common agent reported. There were 106 fatalities, comprising 1.5% of all registry cases. Major trends in demographics and exposure characteristics remained similar to past years' reports. Sub-analyses were conducted to describe exposures in elderly patients, addiction consultation practices, and risk factors for bupropion-induced seizures. The launch of the ToxIC Qualified Clinical Data Registry (TQCDR) is also described.
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http://dx.doi.org/10.1007/s13181-019-00736-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6825068PMC
October 2019

Child and adolescent benzodiazepine exposure and overdose in the United States: 16 years of poison center data.

Clin Toxicol (Phila) 2020 07 15;58(7):725-731. Epub 2019 Oct 15.

Georgetown University School of Medicine, Washington, DC, USA.

Recently, there has been an increase in prescription drug abuse and related fatalities. Although opioid analgesics are commonly implicated, there have been significant increases in the prevalence of benzodiazepine exposures and overdoses. To describe national trends in pediatric benzodiazepine exposures from 2000 to 2015. A retrospective database analysis was conducted. Data regarding benzodiazepine exposures in children ages 0 to <18 years reported to participating United States poison centers from January 2000 through December 2015 were obtained from the National Poison Data System. Population data were obtained from the US Census Bureau to determine annual population estimates. Data were analyzed using chi-square tests. A total of 296,838 pediatric benzodiazepine exposures were identified during the study period. The rate of pediatric benzodiazepine exposure increased 54% between 2000 and 2015. The severity of medical outcomes also increased, as did the prevalence of co-ingestion of multiple drugs, especially in children ages 12 to <18 years. Nearly half of all reported exposures in 2015 were documented as intentional abuse, misuse, or attempted suicide, reflecting a change from prior years. The most commonly identified pediatric benzodiazepines of exposures were alprazolam, clonazepam, and lorazepam. The rate and severity of reported pediatric benzodiazepine exposure is increasing over time. Adolescent exposures are of specific concern, as co-ingestion and intentional abuse were found to be more common in this group. Medical providers and caretakers should be cognizant of this growing epidemic to avoid preventable harm to adolescents, young children, and infants.
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http://dx.doi.org/10.1080/15563650.2019.1674321DOI Listing
July 2020

Total Spinal Anesthesia Following an Interscalene Block Treated with Intravenous Lipid Emulsion.

Cureus 2019 Apr 17;11(4):e4491. Epub 2019 Apr 17.

Integrated Medical Science, Florida Atlantic University, Boca Raton, USA.

Total spinal anesthesia following interscalene block is a rare and life-threatening complication of regional anesthesia. A 56-year-old woman underwent an uncomplicated left shoulder bone spur removal under general anesthesia with an interscalene nerve block at an outpatient surgical center. Subsequently, she developed bilateral mydriasis, paralysis of all extremities, and respiratory arrest. She was intubated and transferred to the emergency department (ED) where she was given intravenous lipid emulsion (ILE) with complete recovery of neurological function. ILE therapy may be considered as a rescue treatment in addition to supportive therapy for total spinal anesthesia.
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http://dx.doi.org/10.7759/cureus.4491DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6581388PMC
April 2019

Bismuth Subsalicylate Coagulopathy in a Patient with Chronic Liver Disease.

J Med Toxicol 2019 Jul 6;15(3):198-201. Epub 2019 May 6.

Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA.

Bismuth subsalicylate (BSS) is the active ingredient in over-the-counter antacid and antidiarrheal medications. Coagulopathy in the setting of acetylsalicylic acid toxicity is well documented but not in setting of bismuth subsalicylate overuse. We present a case report of coagulopathy from BSS poisoning in a patient with underlying cirrhosis. The patient's high prothrombin time suggests inhibition of vitamin K-dependent coagulation factors. The patient had decreased factor V activity, which is responsible for converting prothrombin to thrombin. Patients with cirrhosis often have hypoprothrombinemia which may be exacerbated by salicylate-induced coagulopathy. Given the widespread use of BSS products, physicians should recognize coagulopathy as a possible manifestation of toxicity especially in patients with underlying liver disease.
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http://dx.doi.org/10.1007/s13181-019-00709-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6597674PMC
July 2019

Naloxone Deserts in NJ Cities: Sociodemographic Factors Which May Impact Retail Pharmacy Naloxone Availability.

J Med Toxicol 2019 Apr 25;15(2):108-111. Epub 2019 Feb 25.

Rutgers New Jersey Medical School, Newark, NJ, USA.

Introduction: Retail pharmacies in NJ are permitted to dispense naloxone without a prescription. However, not all pharmacies have participated in this effort, and it is not clear what factors may impact its availability. We sought to determine the naloxone availability of select NJ cities and what sociodemographic factors are associated with its availability. We compared naloxone availability in retail pharmacies to median household income, population, and the prevalence of opioid-related hospital visits (ORHV).

Methods: All retail pharmacies in ten New Jersey cities were surveyed by phone in February-July 2017. The standardized survey instrument asked scripted questions to each pharmacist concerning the stocking of naloxone for dispensing. Median household income data and population data for each city were obtained from census.gov . Opioid-related hospital visits were obtained through the NJ SHAD database and the prevalence of ORHV was calculated. Naloxone availability was compared to median household income, population, and ORHV using Spearman's rho and Pearson's correlation.

Results: Naloxone availability in the 90 retail pharmacies we surveyed was 31% and ranged from 15.38 to 66.67% by city. An increase in median household income indicated more pharmacy naloxone availability. An increase in population indicated less pharmacy naloxone availability. While no significant relationship existed between ORHV and pharmacy naloxone availability, we did identify individual cities with severe opioid-related public health concerns with limited naloxone access.

Conclusions: Naloxone deserts exist in select high-risk New Jersey cities, and pharmacy naloxone availability may be positively related to median household income and negatively related to population.
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http://dx.doi.org/10.1007/s13181-019-00700-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6441063PMC
April 2019

Loperamide misuse to avoid opioid withdrawal and to achieve a euphoric effect: high doses and high risk.

Clin Toxicol (Phila) 2019 03 26;57(3):175-180. Epub 2018 Dec 26.

c Department of Emergency Medicine, New Jersey Poison Information and Education System , Rutgers New Jersey Medical School , Newark , NJ , USA.

Introduction: Loperamide is a readily accessible nonprescription medication that is increasingly being used surreptitiously as an opioid substitute to alleviate the symptoms of acute opioid withdrawal. The objective of this study was to determine the clinical characteristics of patients with loperamide misuse and toxicity.

Methods: The ToxIC registry, a nationwide, prospectively collected cohort of patients evaluated by medical toxicologists was searched from November 2011-December 2016 for patients with loperamide exposure. Each record was reviewed to determine the circumstances, dose, clinical presentations, treatment, and outcomes associated with loperamide use.

Results: Twenty-six cases were identified, and both the absolute number and relative proportion of overall cases in the ToxIC registry increased annually. The median age was 27 and 54% were male. Of cases with known intent (n = 18), 12(67%) were misuse/abuse, 3(17%) were self-harm/suicide, and 3(17%) were pediatric exploratory ingestions. Circumstances for misuse included taking higher doses than labeled (n =7), avoiding withdrawal (n = 6), and gaining a pleasurable sensation (n =4). The dose was reported in nine cases and ranged from 4 mg to 400 mg. In patients seeking to avoid withdrawal doses were 160-400 mg/day; the most common reported dose was 200 mg. Reported ECG abnormalities included 10 cases of prolonged QTc (>500 ms), which consisted of misuse/abuse (n =6) and self-harm (n =1) exposures; six prolonged QRS (>120 ms); two first degree AV block; seven ventricular dysrhythmias, five of which were single-agent exposures. All but one ECG demonstrated prolonged QTc with a range of 566-749 ms. All patients with dysrhythmias in which dose were reported ingested ≥200 mg.

Conclusions: The majority of patients had loperamide toxicity due to misuse/abuse, in-line with national trends. In patients avoiding withdrawal, doses >100 mg were observed. When taken in large doses (>200 mg), loperamide may cause significant cardiovascular effects, including QTc-prolongation and ventricular dysrhythmias.
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http://dx.doi.org/10.1080/15563650.2018.1510128DOI Listing
March 2019

Correction to: The Toxicology Investigators Consortium Case Registry-The 2017 Annual Report.

J Med Toxicol 2018 Dec;14(4):333

University of Colorado School of Medicine, 13001 E 17th Pl, Aurora, CO, 80045, USA.

Please note the Collaborators for this article listed in the Acknowledgements.
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http://dx.doi.org/10.1007/s13181-018-0681-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6242793PMC
December 2018

Predictable, Preventable, and Deadly: Epidemic Carbon Monoxide Poisoning After Storms.

Am J Public Health 2018 10;108(10):1320-1321

Fred M. Henretig and Kevin C. Osterhoudt are with the Division of Emergency Medicine and The Poison Control Center, Children's Hospital of Philadelphia, Philadelphia, PA. Fred M. Henretig is also with the Leonard Davis Institute of Health Economics, University of Pennsylvania. Diane P. Calello is with the Department of Emergency Medicine, Rutgers New Jersey Medical School and the New Jersey Poison Information and Education System, Newark. Michele M. Burns is with the Division of Pediatric Emergency Medicine, Boston Children's Hospital and the Massachusetts & Rhode Island Poison Control Center, Boston. Katharine A. O'Donnell is with the Department of Medicine, Programs in Hospital Medicine and Medical Toxicology, Boston Children's Hospital and the Massachusetts & Rhode Island Poison Control Center.

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http://dx.doi.org/10.2105/AJPH.2018.304619DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6137758PMC
October 2018
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