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More about phenibut
3.5 out of 5 stars Phenibut (β-Phenyl-GABA): A Tranquilizer and Nootropic Drug. Lapin I. CNS Drug Rev 2001;7:471-481. Abstract Since posting about phenibut yesterday, I wondered how much medical literature existed describing its pharmacology and toxicology. This paper — not included in the  the initial accepted manuscript of O’Connell et al but referenced in the Wikipedia entry on phenibut — is the most complete discussion I found. However,  phenibut was first synthesized and used medically in the Soviet Union half a century ago and there undoubtedly is considerable literature published in Russian that I can...
Source: The Poison Review - April 22, 2014 Category: Toxicology Authors: Leon Tags: Medical dietary supplement GABA agonist phenibut Source Type: news

Toxicity from phenibut, a legal over-the-counter baclofen analogue
3 out of 5 stars Phenibut, the appearance of another potentially dangerous product in the Univted States. O’Connell CW et al. Am J Med 2014 Apr 5 [Epub ahead of print] Reference This short case report describes a 25-year-old man who was brought to the emergency department after being found with decreased mental status and responsiveness. On arrival at the hospital, his vital signs were stable and pulse oximetry 100% on room air. He was minimally responsive to painful stimuli. Neurological exam was non-focal and head CT unremarkable. A roommate reported that the patient had been taking 1.5 grams of “Phenibut...
Source: The Poison Review - April 22, 2014 Category: Toxicology Authors: Leon Tags: Medical baclofen GABA agonist legal high noofen phenibut sedative Source Type: news

Tox Tunes #81: Junko Partner (Dr. John)
http://www.youtube.com/watch?v=BqfH_1xCSME This is a great version of the blues standard from Dr. John‘s 1972 album Gumbo. The song has been covered by everyone from Professor Longhair to The Clash. The liner notes call this song “the anthem of the dopers, the whores, the pimps, the cons”: Lee Allenwails on this one, how many tenor choruses does he have, four? I love it! The song was first made popular by James Wayne’s hit on the “Sittin’ In” (Bob Shad’s) label. But it was a New Orleans classic; the anthem of the dopers, the whores, the pimps, the cons. It was a song they s...
Source: The Poison Review - April 20, 2014 Category: Toxicology Authors: Leon Tags: Medical dr. john junco partner junko partner tox tunes Source Type: news

Rocky Mountain Poison Center Staff Discuss Legalized Pot in Colorado
Dr. Eric Lavonas,  associate director of the Rocky Mountain Poison and Drug Center, discussed the situation with legalized cannabis in Colorado on 710KNUS in Denver. He noted that the 3 main problems emergency departments have been dealing since legalization have been psychotic reactions from persons not accustomed to the potency of the marijuana that’s on the market, the severe vomiting that some users experience, and children who inadvertently ingest cannabis edibles (candy, brownies cookies, etc) and show up with altered behavior. Dr. Lavonas also touched on the problem of users “stacking” doses of ed...
Source: The Poison Review - April 19, 2014 Category: Toxicology Authors: Leon Tags: Medical al bronstein cannabis colorado denver edible eric lavonas marijuana rocky mountain poison center Source Type: news

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Dr. Eric Lavonas,  associate director of the Rocky Mountain Poison and Drug Center, discussed the situation with legalized cannabis in Colorado on 710KNUS in Denver. (Source: The Poison Review)
Source: The Poison Review - April 19, 2014 Category: Toxicology Authors: Leon Tags: Medical Source Type: news

Supercut: death by poison
Inspired by the Game of Thrones episode last night and (SPOILER ALERT) King Joffrey’s richly deserved dispatch by poison, this supercut of poisonings in movies and on TV comes from Abraham Riesman and vulture.com. (Source: The Poison Review)
Source: The Poison Review - April 14, 2014 Category: Toxicology Authors: Leon Tags: Medical death by poisoning film movies supercut television Source Type: news

What a day for a daydream (pass the Adderall)
http://www.youtube.com/watch?v=SLeGbDx_9eM In a recent “Toxicology Rounds” column in Emergency Medicine News, I pointed out that the American Psychiatry Association and the latest edition of its publication, the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) have been expanding the criteria for diagnosing attention-deficit hyperactivity disorder (ADHD): Criterion “B” in DSM-IV requires that “some hyperactive-impulsive or inattentive symptoms were present before age 7 years.” That same criterion in DSM-V reads: “Several inattentive or hyperactive-impulsive symptoms were present prior to ...
Source: The Poison Review - April 14, 2014 Category: Toxicology Authors: Leon Tags: Medical ADHD attention deficit hyperactivity disorder sluggish cognitive disorder Source Type: news

Effects of marijuana on driving ability
4.5 out of 5 stars Medical Marijuana and Driving: a Review. Neavyn MJ et al. J Med Toxicol 2014 Mar 20 [Epub ahead of print] Abstract This excellent and comprehensive review of literature related to the possible effects of marijuana on driving skills is a must-read for anyone dealing with forensics and medical-legal cases related to the topic, or consulting with government agencies on regulatory issues. It is also helpful for any clinician who might have to counsel patents about driving and the use of medical marijuana. The 70-item reference list alone will be a great resource for further study. As the article points out,...
Source: The Poison Review - April 9, 2014 Category: Toxicology Authors: Leon Tags: Best of TPR Medical cannabis driving impairment marijuana THC Source Type: news

Death after use of recreational marijuana, and other Tox on the Web
More on e-cigarette nicotine liquid: On KSTP-TV news in Minneapolis/St. Paul, medical toxicologist Dr. Ben Orozco discusses the hazards of e-cigarette refill liquid, and the signs and symptoms of nicotine toxicity. Suicide by hydrogen sulfide: The St. Charles (LA) Herald-Guide reported the tragic story about a 32-year-old research scientist who killed herself by releasing hydrogen sulfide in her car. She had posted hazmat warnings in the windows to protect first responders. TPR has written previously about these s0-called “chemical suicides,” a phenomenon that started in Japan and often takes place in the v...
Source: The Poison Review - April 8, 2014 Category: Toxicology Authors: Leon Tags: Medical ADHD driving e-cigarette fluoroquinonlone adverse effects hydrogen sulfide magic mushroom marijuana marijuana death motor vehicle collisions nicotine opiates opioids poison ivy poison oak psilocybin suicide traffi Source Type: news

Calls to poison centers related to nicotine-containing e-cigarette liquid skyrocketing
The Centers for Disease Control and Prevention released results from a study showing that reported exposures to nicotine-containing e-cigarette liquid have risen dramatically over the last several years. Their data indicates that in September 2010, U.S. poison centers received just a single call related to these liquids. In February 2014, that number had increased to 215 calls for the month. Over half the calls involved children less than 5 years of age. Routes of exposure included ingestion, inhalation, or absorption through skin or eyes. The refill liquids, that can contain more than the minimal dose of nicotine that ca...
Source: The Poison Review - April 5, 2014 Category: Toxicology Authors: Leon Tags: Medical e-cigarettes nicotine toxicity vaping Source Type: news

Do two dissimilar cases represent a case series?
2 out of 5 stars High-dose Insulin and Intravenous Lipid Emulsion Therapy for Cardiogenic Shock Induced by Intentional Calcium-Channel Blocker and Beta-Blocker Overdose: A Case Series. Doepker B et al. J Emerg Med 2014 Apr;46:486-490.   Abstract The problems with this confused and confusing paper start with the title, which suggests that it will describe a series patients who presented with overdose of a calcium-channel blocker (CCB) and beta-blocker (BB), who were treated with high-dose insulin (HDI) and intravenous lipid emulsion (ILE). Well, this may be a case series, but the series includes only 2 patients, and ...
Source: The Poison Review - April 3, 2014 Category: Toxicology Authors: Leon Tags: Medical beta blocker overdose calcium channel blocker overdose high-dose insulin intralipid intravenous fat emulsion Source Type: news

Just when you thought it was safe to enjoy a refreshing ice tea . . .
3 out of 5 stars Multiple Poisonings with Sodium Azide at a Local Restaurant. Schwarz ES et al. J Emerg Med  2014 Apr;46:491-494. Abstract This is an interesting report describing at incident in April 2010 in which 5 persons came down with symptoms of sodium azide poisoning after drinking ice tea from the same self-serve urn at a local restaurant. All patients recovered. Unfortunately, this paper does not add much to the complete report published in MMWR 2 years ago, except for some additional detail about individual patients and the treatments they received. To read TPR‘s discussion of the MMWR report, click he...
Source: The Poison Review - April 2, 2014 Category: Toxicology Authors: Leon Tags: Medical ice tea sodium azide toxicity Source Type: news

Tox Tunes #80: Weed Head Woman (Champion Jack Dupree)
http://www.youtube.com/watch?v=_Ge5IgTHBDk The great boogie-woogie blues pianist Champion Jack Dupree (?1908 – 1992) got his nickname from the fairly successful boxing career that preceded his taking up music as a career. According to wikipedia, after being encouraged by Joe Louis he entered 107 fights, winning the Golden Gloves and other championships. Although he was originally from New Orleans, Dupree did much of his early recording in Chicago. “Weed Head Woman” was recorded in 1941. In 1966, he jammed with Eric Clapton and John Mayall: http://www.youtube.com/watch?v=SbUnVxwxKoE Related posts: Tox Tu...
Source: The Poison Review - March 30, 2014 Category: Toxicology Authors: Leon Tags: Medical champion jack dupree tox tunes weed head woman Source Type: news

Complications associated with lipid emulsion therapy
3 out of 5 stars Complications Following Antidotal Use of Intravenous Lipid Emulsion Therapy. Levine M et al. J Med Toxicol 2014 Mar;10:10-14. Abstract Known complications of intralipid administration include pancreatitis, acute respiratory distress syndrome (ARDS), and interference with laboratory tests. While these complications can be seen when intralipid is administered for parenteral nutrition, there is interest concerning to what extent they occur when lipid emulsion therapy (LET) is given as a rescue antidote to treat lipophilic drug toxicities. The authors retrospectively reviewed registries at two tertiary care m...
Source: The Poison Review - March 28, 2014 Category: Toxicology Authors: Leon Tags: Medical adverse event antidote complication intralipid emulsion therapy Source Type: news

Dutch marijuana trade, German meth, and more! Tox on the Web
The politics and economics of marijuana in the Netherlands: The above piece from PBS NewsHour makes the point that the illogical patchwork system controlling the market for recreational cannabis in the Netherlands is nothing like the comprehensive regulation being instigated in Colorado and Washington state. HT @erowid) Must-read: Meth in Germany: A recent issue of Der Spiegel has an extensive report on the growing problem of methamphetamine abuse in Germany. Apparently, much of the meth is manufactured in Czechoslovakia and slipped across the border. Many of the people who become hooked on the drug are students and you...
Source: The Poison Review - March 26, 2014 Category: Toxicology Authors: Leon Tags: Medical cannabis chemical warfare agents Georgetown germany liquid nicotine marijuana methamphetamine netherlands Redstone arsenal ricin Source Type: news

ED discharge prescriptions for opioid analgesics increased 49% from 2005 to 2010
3 out of 5 stars Rising Opioid Prescribing in Adult U.S. Emergency Department Visits: 2001-2010. Mazer-Amirshahi et al. Acad Emerg Med 2014 Mar;21:236-243. Abstract The Centers for Disease Control and Prevention has called prescription drug overdose “the fastest growing drug problem in the United States” and an “epidemic.” Most physicians are astounded when first informed about the extent of this problem. Test your knowledge: How many people died in the United States of prescription drug overdose during the year 2010? Click here for the answer. expand(document.getElementById('ddet426749948'));expan...
Source: The Poison Review - March 25, 2014 Category: Toxicology Authors: Leon Tags: Medical abuse emergency department fatality opioid overdose Source Type: news

TPR Podcast Episode #3: Kaboom! – Exploding Toxicology
Episode 3 kaboom v2Episode 3: Kaboom! – Exploding Tox Written by Theresa Kim   Outline 1)     “Wax” or “dab” 2)     Meth lab explosions 3)     Smoking stool syndrome 4)     Ingestion of fireworks 5)     Nitropatch 6)     Bonus topic related to the prior discussion of Hunan hand and food related tox   Wax or Dab A nearly pure form of THC called “wax” or “dab” can be extracted from marijuana using a volatile hydrocarbon solvent (usually butane) Name derived from the wax-like quality of the final product Numerous reports of explosions at home “wax” labs Legal in Colorad...
Source: The Poison Review - March 24, 2014 Category: Toxicology Authors: LeonThe Poison Review Tags: Podcast Source Type: news

Cases of ADHD are skyrocketing: epidemic or conspiracy?
Data suggest that cases of ADHD are skyrocketing. One in nine children receive the diagnosis by age 18, and 70% of these are prescribed stimulants or other medications. Dr. William Graf, professor of Pediatrics and Neurology at Yale, told the New York Times “These are astounding numbers. I’m floored.” But things are about to get worse. Under new criteria published in the recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), even more children will quality for the diagnosis. This will almost certainly increase the number of prescriptions for ADHD drugs and, inevitably, incr...
Source: The Poison Review - March 19, 2014 Category: Toxicology Authors: Leon Tags: Medical adderall ADHD attention deficit hyperactivity disorder Emergency Medicine News Ritalin toxicology rounds Source Type: news

Was Beethoven’s deafness caused by lead toxicity?
3 out of 5 stars Lead and the Deafness of Ludwig Van Beethoven. Stevens MH et al. Laryngoscope 2013 Nov;123:2854-2858. Abstract Beethoven was 27 when he first experienced tinnitus and high-frequency hearing impairment. These symptoms progressed slowly until the famous incident in 1824 when the composer, attending the first performance of his Ninth Symphony, he was not able to hear the thunderous applause that followed. The authors of this interesting article consider some previously theories proposed to explain Beethoven’s deafness, and find reasons to rule them out: Autoimmune hearing loss – While this progr...
Source: The Poison Review - March 17, 2014 Category: Toxicology Authors: Leon Tags: Medical beethoven deafness hearing loss lead ototoxicity plumbism Source Type: news

Imagine
With the SMACC Gold conference starting in just 3 days, the excitement is building and there is music in the air in Queensland.  All power to FOAMed! The above bit of FOAMaoke is from Simon Carley and the St. Emlyn’s blog. (Source: The Poison Review)
Source: The Poison Review - March 16, 2014 Category: Toxicology Authors: Leon Tags: Medical FOAMaoke imagine SMACC st. emlyn's blog Source Type: news

The science of alpha-PVP (“gravel”), a second-generation bath salt
http://www.youtube.com/watch?v=mjoidR3Jfa0 3.5 out of 5 stars Pharmacology of novel synthetic stimulants structurally related to the “bath salts” constituent 3,4-methylenedioxypyrovalerone (MDPV). Marusich JA at al. Neuropharmacology 2014 Mar2 [Epub ahead of print] Abstract Earlier this month TPR noted that a relatively new second-generation bath salt call “gravel” was reported to have surfaced in various parts of the United States, including Tennessee. As background, while first-generation bath salts — MDPV, methylone, and mephedrone — were outlawed in many jurisdictions, new analogues had bee...
Source: The Poison Review - March 15, 2014 Category: Toxicology Authors: Leon Tags: Medical bath salts gravel MDPV PVP Source Type: news

Sriracha, Zohydro, and more: tox on the web
  http://www.youtube.com/watch?v=U2DJN0gnuI8 The science of Sriracha: The American Chemical Society has a must-see video on Sriracha hot sauce — it goes well with everything — including disquisitions about the origin of the Scoville scale and the physiology of capsaicinoids. (HT @ToxTalk) Early ads for sedatives: The Milwaukee Journal-Sentinel — which is doing some of the best reporting in the country on drugs and the pharmaceutical industry — has a great collection of medical journal ads for tranquilizers from the 1950s and 60s.  This post accompanies their story on the deadly interaction between sedat...
Source: The Poison Review - March 5, 2014 Category: Toxicology Authors: Leon Tags: Medical amphetamine drug screen capsaicin did she kill him Florence Maybrick gravel Kate Coloquhoun PVP pyrrolidinopentiophenone scoville scale sedative sriracha tox on the web tranquilizer advertisement zohydro Source Type: news

Central pontine myelinolysis associated with ethylene glycol intoxication
central pontine myelinolysis, MRI 3.5 out of 5 stars Massive Ethylene Glycol Poisoning Triggers Osmotic Demyelination Syndrome. Ahmed A et al. J Emerg Med 2014 Mar;46(3):369-74 Abstract Central pontine myelinolysis has long been associated with too rapid correction of subacute hyponatremia. Although the pathophysiologic mechanism has not yet been fully elucidated, it appears to involve stress from relative serum hyperosmolality and loss of water from brain cells. Endothelial damage and injury to the blood-brain barrier may also play a role. Recently, this process has been renamed osmotic demyelination syndrome (ODS) with ...
Source: The Poison Review - March 4, 2014 Category: Toxicology Authors: Leon Tags: Medical central pontine myelinolysis ethylene glycol toxicity osmolality osmotic demyelination syndrome toxic alcohol Source Type: news

Tox Tunes #79: Muggles (Louis Armstrong)
http://www.youtube.com/watch?v=qY6Yo6lE-Jg In the Harry Potter series, a “muggle” refers to a person without any magical power whatsoever. I’m quite sure Louis Armstrong had something else in mind when he recorded this track in 1928.  It features some magnificent playing, especially by Armstrong on trumpet and Earl Hines on piano. Back in the 1920s, “muggles” was common slang for marijuana, especially among jazz musicians. (Source: The Poison Review)
Source: The Poison Review - March 2, 2014 Category: Toxicology Authors: Leon Tags: Medical earl hines louis armstrong muggles tox tunes Source Type: news

Hyperbaric oxygen for gas emboli following hydrogen peroxide ingestion
Discussion” section of the paper: As little as “one sip” (1-5 ml) of hydrogen peroxide can cause problems. Imaging and endoscopy are appropriate for patients who have ingested solutions > 10% and those who have “significant symptoms.” including persistent abdominal pain, neurologic deficits, or hematemesis. HBO should be considered in patients with gas emboli after ingestion of hydrogen peroxide. The paper is possibly most valuable for its 2 tables, that summarize reported cases of hydrogen peroxide ingestions treated with and without HBO. (Source: The Poison Review)
Source: The Poison Review - February 27, 2014 Category: Toxicology Authors: Leon Tags: Medical gas emboli hydrogen peroxide hyperbaric oxygen Source Type: news

The Dark Side of Acetaminophen, and more: Tox on the Web
  The Dark Side of Acetaminophen: The Toronto Star has a long article this weekend about the hepatotoxicity of acetaminophen, both when taken in deliberate overdose as a suicidal gesture or attempt, or ingested in supra-therapeutic (or even therapeutic) doses.   It was put together with the help of the investigative unit ProPublica and goes over much of the material covered in the recent “This American Life” episode but with a Canadian twist. The piece states that a 2009 report “found a dozen cases in Health Canada’s adverse drug events database where people suffered liver injury or damage aft...
Source: The Poison Review - February 23, 2014 Category: Toxicology Authors: Leon Tags: Medical acetaminophen amitriptyline cyclobenzaprine ethylene glycol hepatotoxicity nasal naloxone tox on the web Source Type: news

TPR Podcast Episode #2: Chinese Restaurant Toxicology
Conclusion: patients with renal dysfunction should be cautious of how much durian they ingest   Summary of Soy Sauce Induced 19 year old male came in comatose after being dared to ingesting a quart of soy sauce 2 hrs prior to arrival Peak sodium 196 The patient received very aggressive fluid hydration 6L D5W Soy sauce is 17-18% NaCl A quart of soy sauce has 160-170gm ~ 10tbsp of NaCl The only critique of the paper is that the use of very aggressive fluid hydration and lowering of sodium should not be generalized to all cases given the risk of central pontine myelinolysis In this case extreme measures and aggressi...
Source: The Poison Review - February 22, 2014 Category: Toxicology Authors: LeonThe Poison Review Tags: Podcast Source Type: news

Why is cocaine adulterated with an animal dewormer? Mystery solved?
3.5 out of 5 stars Aminorex, a metabolic of the cocaine adulterant levamisole, exerts amphetamine like actions at monoamine transporters. Hofmaier T et al. Neurochem Int 2013 Dec 1 [Epub ahead of print] Abstract During the last decade, many shipments of cocaine seized by U.S. drug authorities have been found to be adulterated with levamisole, a veterinary anti-worming medicine. The drug in the past has been used to treat various medical conditions in humans, but was withdrawn from the market because of significant  adverse reactions. Levamisole has also been associated with the occurrence of agranulocytosis and dermal ...
Source: The Poison Review - February 21, 2014 Category: Toxicology Authors: Leon Tags: Medical adulterated aminorex cocaine levamisole Source Type: news

Driving under the influence (of marijuana)
How safe is driving under the influence of marijuana? For forensic purposes, are there tests that can establish impairment from THC? If so, how can they be used fairly and accurately. These are important questions now — especially in the states of Washington and Colorado — and they are explored in a very interesting article by Maggie Koerth-Baker in this morning’s New York Times science section. One can argue about the use of roadside field sobriety tests and Breathalyzer results to demonstrate driving under the influence of alcohol — lawyers hash out these issues in coatrooms every day — but the science b...
Source: The Poison Review - February 19, 2014 Category: Toxicology Authors: Leon Tags: Medical automobile cannabis driving marijuana THC Source Type: news

Asystole shortly after intravenous fat emulsion for overdose: causation or coincidence?
3 out of 5 stars Asystole Immediately Following Intravenous Fat Emulsion for Overdose. Cole JB et al. J Med Toxicol 2014 Feb 12. [Epub ahead of print] Abstract This case paper describes 2 patients who developed asystolic within 60 seconds of being given intravenous fat emulsion (IFE) bolus for treatment of severe cardiotoxicity. Both patients had return of spontaneous circulation (ROSC) after several minutes of cardiopulmonary resuscitation. Unfortunately, both patients died days after admission from multisystem organ failure. Patient A,  a 50-year-old woman, had ingested an undetermined about of metoprolol and bupropion...
Source: The Poison Review - February 18, 2014 Category: Toxicology Authors: Leon Tags: Medical asystole bupropion cardiac arrest diltiazem intralipid intravenous fat emulsion therapy metoprolol propranolol Source Type: news

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<script type="text/javascript" src="http://video.foxnews.com/v/embed.js?id=3211736681001&w=466&h=263"></script><noscript>Watch the latest video at <a href="http://video.foxnews.com">video.foxnews.com</a></noscript> (Source: The Poison Review)
Source: The Poison Review - February 17, 2014 Category: Toxicology Authors: Leon Tags: Medical Source Type: news

Tox Tunes #78: Needle of Death (Neil Young)
http://www.youtube.com/watch?v=kfxNkhrJqSM This beautiful cover version of Bert Jansch’s “Needle of Death” by Neil Young is from a concert at Carnegie Hall’s Isaac Stern auditorium this past January. The visuals and the sound aren’t much — the clip was recorded from the balcony seats — but I find the performance moving anyway, especially at this time when the number of heroin overdose deaths are increasing dramatically. This song is a fitting companion to Young’s own “The Needle and the Damage Done.”   (Source: The Poison Review)
Source: The Poison Review - February 16, 2014 Category: Toxicology Authors: Leon Tags: Medical bert jansch needle of death neil young tox tunes Source Type: news

6 Pearls About Metformin and Lactic Acidosis
3.5 out of 5 stars Metformin accumulation: Lactic acidosis and high plasmatic metformin levels in a retrospective case series of 66 patients on chronic therapy. Vecchio S et al. Clin Toxicol 2014 Feb;52:129-135. Abstract Metformin is frequently used alone or in combination to treat type 2 diabetes. It lowers blood glucose by decreasing hepatic gluconeogenesis, predominantly by inhibiting mitochondrial respiratory chain complex I. The drug is eliminated mainly by the kidneys, and acute or chronic renal insufficiency may allow accumulation of the drug with increasing levels. A small percentage of patients on metformin devel...
Source: The Poison Review - February 13, 2014 Category: Toxicology Authors: Leon Tags: Medical glucophage lactic acidosis MALA metabolic acidosis metformin Source Type: news

You don’t need Dr. House to suspect cobalt toxicity in a patient with an artificial hip
Dr. Gregory House 3 out of 5 stars Cobalt intoxication diagnosed with the help of Dr. House. Dahms K et al.  Lancet 2014 Feb 8;383:574. Full text This is a neat short case report that can fix in the mind the features of cobalt toxicity. A 55-year-old man came to clinic with a history of: severe heart failure (ejection fraction = 25%) decreased hearing acuity decreased visual acuity fever of unknown origin hypothyroidism abdominal discomfort lymphadenopathy All signs and symptoms seemed to have developed over the year before presentation. Further history revealed that the patient had undergone bilateral hip replacement. ...
Source: The Poison Review - February 12, 2014 Category: Toxicology Authors: Leon Tags: Medical artificial hip prosthesis cobalt toxicity dr. gregory house Source Type: news

Tox on the Web: the resurgence of heroin abuse, and more
  The death of actor Philip Seymour Hoffman last week prompted a slew of articles about the related problems of prescription opioid abuse and heroin addiction. In the Washington Post, Joel Achenbach points out that despite the recent spike in deaths from heroin overdose, recent data indicated that “[p]rescription opioids are killing Americans at more than five times the rate that heroin is.” Achenbach also notes that use of heroin is increasing as individuals addicted to opioid pain relievers turn to the cheaper and more available street drug.  CBCNews reported on a similar trend in Canada (clip above). ...
Source: The Poison Review - February 10, 2014 Category: Toxicology Authors: Leon Tags: Medical azodiacarbonamide buprenorphine butane oil cannabis dab giant hornet hash oil helium heroin overdose hyperthermia marijuana methadone naloxone opiate pain relievers oxycodone philip seymour hoffman serotonin syndr Source Type: news

Maybe Pradaxa (dabigatran) does need blood monitoring after all
2.5 out of 5 stars The Effect of Dabigatran Plasma Concentrations and Patient Characteristics on the Frequency of Ischemic Stroke and Major Bleeding in Atrial Fibrillation Patients. Reilly PA et al. J Am Coll Cardiol 2014 Feb 4;63:321-8. Abstract A must-read article in yesterday’s New York Times described the internal battle at Boehringer Ingelheim, the maker of Pradaxa (dabiagtran etexilate), concerning the publication of this study. A major marketing point posited in favor of dabigatran over warfarin for the prevention of stroke in patients with atrial fibrillation was that it did not require monitoring with reg...
Source: The Poison Review - February 7, 2014 Category: Toxicology Authors: Leon Tags: Medical bleeding blood testing boehringer ingelheim dabigatran pradaxa stroke Source Type: news

Episode #1 Addendum
Discussion of the reappearance of the krokodil report as a letter to the editor Critique of the revised report Definition of a case report   Critique of the Revised Krokodil Report Revision has improved grammar and sentence structure Content, however, still flawed: Unsupported claim that krokodil is rapidly spreading across Europe Krokodil  loosely called  “homemade heroin” — it’s actually desomorphine or the product formed from the attempt to manufacture desomorphine from codeine and caustic reagents Use of sensationalized terms such as “flesh eating” which are more appropriate for non-medical journa...
Source: The Poison Review - February 5, 2014 Category: Toxicology Authors: LeonThe Poison Review Tags: Podcast Source Type: news

The money and influence behind “Pain: the 5th vital sign”
“Last year, [Philip Seymour Hoffman] checked into a rehabilitation program for about 10 days, a move that came after a reliance on prescription pills led to a return to heroin, after what he said had been a clean period spanning two decades.” New York Times February 4, 2014 The death of actor Philip Seymour Hoffman from a drug overdose earlier this week brings into focus not only the recent resurgence of heroin use, but also the dangers of prescription opioid pain relievers. It seems an appropriate time to rerun this post from December 2012.   A must-read article in the Wall Street Journal this weekend focus...
Source: The Poison Review - February 5, 2014 Category: Toxicology Authors: Leon Tags: Medical heroin opiate opioid opioid pain relievers pain the 5th vital sign philip seymour hoffman Source Type: news

Bud Light commercial too toxic for the Super Bowl
http://www.youtube.com/watch?v=cYIN-b8qjmo This toxicology-themed Bud Light commercial was banned from airing during the 2007 Super Bowl. (Source: The Poison Review)
Source: The Poison Review - February 2, 2014 Category: Toxicology Authors: Leon Tags: Medical blowfish bud light fugu super bowl Source Type: news

Breaking Dab: a potent and explosive form of THC
A few weeks ago, NPR’s news show All Things Considered reported on “wax” or “butane hash oil” or “dab”, a highly concentrated form of tetrahydrocannabinol (THC) extracted from marijuana in a process using butane as a solvent. Butane is, of course, highly flammable, and there have been an increasing number of reported explosions caused by individuals trying to make this stuff at home: http://www.youtube.com/watch?v=34GlKQwMFJU This situation has obvious analogy to the dangers involved in meth labs. (“Breaking Dab”?) Aside from creating a danger during manufacture of &#...
Source: The Poison Review - February 1, 2014 Category: Toxicology Authors: Leon Tags: Medical butane butane hash oil dab honey marijuana tetrahydrocannabinol THC wax Source Type: news

Ethylene glycol intoxication can cause falsely elevated lactate levels
3 out of 5 stars The importance of the osmolality gap in ethylene glycol intoxication. Oostvogels R et al. BMJ 2013 Dec 7;347:31-33. Reference – no abstract available This brief case report teaches a key lesson. A 32-year-old woman on multiple sedative and antipsychotic medications presented to the emergency department with decreased mental status. Initially, the treating physicians suspected overdose from one or more of the patients prescription medications. However, they noted an elevated anion gap (23) and an serum lactate level of 25.9 mmol/L (reference 0.0-2.2) for which there was no obvious explanation.   The...
Source: The Poison Review - January 31, 2014 Category: Toxicology Authors: Leon Tags: Medical ethylene glycol toxicity lab error lactate lactic acid oxalate Source Type: news

Bruce Springsteen on Pete Seeger
http://www.youtube.com/watch?v=B4i8ziSHkNA Wonderful tribute by The Boss at Seeger’s 90th birthday celebration. Pete’s and his music were a lifelong inspiration for me, from “Goodnight, Irene” to “The Weavers at Carnegie Hall” to his environmental work with the Hudson River Sloop Clearwater Foundation. And there was, always, his unwavering and indomitable political courage. This incredible performance was aired on CBS’s The Smothers Brothers Comedy Hour in 1968, in the midst of the war in Vietnam: http://www.youtube.com/watch?v=uXnJVkEX8O4 When Toshi Seeger, whom Pete married in 19...
Source: The Poison Review - January 28, 2014 Category: Toxicology Authors: Leon Tags: Medical Source Type: news

Epidemic of heroin/fentanyl overdose deaths in Western Pennsylvania
KDKA-TV, the local CBS station in Pittsburgh, reported yesterday that at least 22 people have died recently from narcotic overdoses in Western Pennsylvania. Authorities believe the deaths are related to products containing heroin and/or  fentanyl sold on the street and derived from supplies stamped with the labels “Theraflu,” “Bud Ice,” or “Income Tax.’ This outbreak is reminiscent of previous events. In the early 1990s, fentanyl-laced heroin sold as “Tango and Cash” killed dozens of victims. In 2006, the Philadelphia Medical Examiner’s Office reported 252 overdose dea...
Source: The Poison Review - January 28, 2014 Category: Toxicology Authors: Leon Tags: Medical fentanyl heroin western pennsylvania Source Type: news

Case series: toxicity from a new synthetic cannabinoid
3.5 out of 5 stars An Outbreak of Exposure to a Novel Synthetic Cannabinoid. Monte AA et al. New Engl J Med 2014 Jan 23;370:389-390. Full Text Last month, TPR posted about an MMWR report describing a markedly increased number of visits to Colorado emergency departments by patients related to smoking synthetic cannabinoid products. This spike in visits occurred in August-September 2013. This letter to the editor describes this same outbreak as seen at 2 teaching hospitals in the Denver area. These institutions saw a combined total of 76 patients. Presenting symptoms included altered mental status, tachycardia (followed by ...
Source: The Poison Review - January 27, 2014 Category: Toxicology Authors: Leon Tags: Medical black mamba colorado crazy clown spice synthetic cannabinoid Source Type: news

Tox Tunes #77: Cooksferry Queen (Richard Thompson)
http://www.youtube.com/watch?v=fGKkhUkxvc4 The narrative of this song is somewhat murky, but seems to involve a gangster or politician (Mulvaney) in a dingy town “with no future” who gets turned on by psychedelic drugs given to him by his “Cooksferry Queen” She gave me one pill to get bigger She gave me one pill to get small I saw snakes dancing all around her feet And dead men coming through the wall According to some online commenters, Cook’s Ferry was a club that Thompson frequented in the 1960s. In this clip, I believe Danny Thompson (no relation) —  formerly with the folk-rock group Pe...
Source: The Poison Review - January 26, 2014 Category: Toxicology Authors: Leon Tags: Medical cooksferry queen richard thompson tox tunes Source Type: news

Justin Bieber arrest refocuses spotlight on “sizzurp”
Visit NBCNews.com for breaking news, world news, and news about the economy   [In the video above, the Today show's Jeff Rossen explains why "sizzurp" — a drug favored by some rap music and pop stars — is so dangerous.] Reports describing the arrest of pop star Justin Bieber, 19,  this week for driving under the influence — after he was stopped while apparently drag racing his Lamborghini in Miami Beach — often mentioned that one of his favorite drinks is “sizzurp“, a potentially lethal mix of prescription cough syrup (codeine and promethazine), soda pop, and hard candy. TPR wrote about this con...
Source: The Poison Review - January 24, 2014 Category: Toxicology Authors: Leon Tags: Medical codeine jolly roger justin beiber promethazine purple drank sizzurp today show Source Type: news

Drug overdose deaths surge in Rhode Island: Tox on the Web
  http://www.youtube.com/watch?v=d05jOFCV3jE Overdose deaths spike in Rhode Island: The Providence Journal reported that during the first 13 days of this year, 22 people in Rhode Island died of drug overdose. Tests on 13 victims revealed the presence of fentanyl — but not acetylfentanyl, a potent analog that 1n 2013 caused at least 14 overdose deaths in the state over the course of just 3 months. One official suggested that the increased number of OD deaths might be related to the push to fight prescription opioid overdose: Michelle McKenzie, senior project director at The Miriam Hospital, who has done extensive ...
Source: The Poison Review - January 23, 2014 Category: Toxicology Authors: Leon Tags: Medical 4-methylcyclohexane anion gap metabolic acidosis elk river fentanyl overdose deaths recast rhode island rob roman sean nordt west virginia Source Type: news

Dabigatran-related bleeding: a case series
2 out of 5 stars Clinical Experience of Life-threatening Dabigatran-Related Bleeding at a Large, Tertiary Care, Academic Medical Center: a Case Series. Ross B et al. J Med Toxicol  2014 Jan 3 [Epub ahead of print] Abstract The authors retrospectively reviewed patients on dabigatran (Pradaxa) admitted to UMass Memorial Medical Center (Worcester) for bleeding. They identified 7 patients with intracranial hemorrhage (ICH) and 4 patients with gastrointestinal bleeding.  Although they present copious information regarding baseline characteristics, treatment modalities and outcomes, with a study population this small and non-...
Source: The Poison Review - January 21, 2014 Category: Toxicology Authors: Leon Tags: Medical bleeding case series dabigatran gastrointestinal bleeding hemorrhage intracranial hemorrhage pradaxa recombinant factor VIIa Source Type: news

The Poison Review Podcast
The Poison Review is pleased to announce that the long-planned TPR podcast has finally arrived.  Actually, this is a resurrection of a project that began back in 1992, when TPR was a hard-copy newsletter with an accompanying audio program that was sent out on cassette tape. We were, of course, inspired by the masters of innovative medical education — Drs. Rick Bukata and Jerry Hoffman — whose Emergency Medical Abstracts project had started in the mid-1970s, and demonstrated to all that continuing medical education need be neither boring nor gullible. For a (very) fanciful history of the old TPR, see this post f...
Source: The Poison Review - January 18, 2014 Category: Toxicology Authors: Leon Tags: Medical podcast the poison review theresa kim Source Type: news