Podcasts about clinical toxicology

Dr. Kareem Ali is an Egyptian doctor and medical educator specializing in clinical toxicology and therapeutic nutrition. He graduated from Al-Azhar University in 2001 and earned his Ph.D. in Clinical Toxicology in 2013. Dr. Ali also holds a Master's in Family Medicine from the University of Oradea in Romania.As a passionate advocate for health education, he is the founder of several YouTube channels, including Fekr Tany Channel, Dr. Kareem Ali Channel, and New Thought Channel, where he shares his medical expertise and insights on health and wellness.Dr. Ali is also the author of the FekrTany Encyclopaedia, a comprehensive work on health topics, with four volumes published by 2021. He has dedicated his career to advancing knowledge in toxicology, nutrition, and preventive healthcare.#hikmatwehbipodcast #kareemali#podcast#arabicpodcast#hikmatwehbipodcast #wstudiodxbحكمت_وهبي#حكمت_وهبي_بودكاست##

In this VETgirl online veterinary continuing education podcast, in recognition of National Poison Prevention Week, we interview Dr. Tina Wismer, MS, DABVT, DABT, Senior Medical Director at the ASPCA Animal Poison Control Center, based out of Urbana, Illinois about the biggest toxicology updates veterinary professionals need to be aware of! Tune in to learn the evidence-based, clinically applicable toxicology updates that save lives... from the difference between activated charcoal and cholestyramine to using fluid therapy in the poisoned patient, you'll want to tune in!Sponsored By:

In this exciting live episode from the 2024 North American Congress of Clinical Toxicology (NACCT) in Denver, Ryan dives into 12 of the most impactful research abstracts presented at the conference directly with the authors themselves. Covering a wide range of toxicology topics—from the NACSTOP2 trial on acetaminophen overdose, ECG intervals, cannabis toxicity in young children, and more—each guest breaks down their study's findings and clinical relevance. If you missed the conference or want a deeper understanding of the year's most important toxicology research, this episode is for you. Check the show notes for links to the published abstracts, the full list of studies discussed, and time stamps for where you can find those studies.   This description highlights the live format, the inclusion of the authors, and the variety of topics discussed. Let me know if you need any tweaks!Link to published abstract manuscriptAbstracts07:48-Abstract #1. The NACSTOP2 trial: a multi-center randomized controlled trial investigating the early cessation of n-acetylcysteine in acetaminophen overdoseGuest- Dr. Anslem Wong, MD, PhD21:33- Abstract  #36. ECG intervals: does one size really fit all?Guest- Dr. Caitlin Roake, MD, PhD25:41- Abstract #85. Do abnormal electrocardiographic intervals predict death in poisoned patients older than 65 years?Guest- Dr. Michael Chary, MD30:06- Abstract #61. Minimum tetrahydrocannabinol dose that produces severe symptoms in children

Intentional poisoning deaths in the U.S. have significantly increased, according to a report in Clinical Toxicology. Over 15 years, poison control center data shows a rise in both adult and pediatric intentional poisonings. Pediatric deaths from poisoning have increased by over 122%, with major effect incidents up by over 190%. For adults, intentional poisoning incidents have risen by nearly 234%, with major effects up by over 133%.  

Dr. Farooqi started her training in Nutrition in Oxford, England, with a focus on maternal nutrition. After completing her studies in England she pursed a Doctorate of Pharmacy from University of Rhode Island followed by a fellowship in Clinical Toxicology with University of New Mexico. She is also a registered yoga teacher having undergone training with Yoga Medicine® and is on her way to complete 500 hour training. Mariya's field experience through training, hospital, and community practices has focused on the understanding of chronic pain, gut health, importance of nutrition in mental health as well as nutritional deficiencies and excesses. Combined with more than fifteen year of client-interaction experience, Mariya's additional knowledge in functional medicine comes from attending seminars and conferences. She has applied several evidence-based principles to achieve wanted outcomes.

Today's episode is going to feature one of the later monarchs from the Hellenistic era- Mithridates VI of Pontus. This is because his practice of trying to make himself immune to poison- called mithridatism- is biologically relevant and and continues to be influential until the 18th century. Sources for this episode: Jarcho, S. (1972), Medical Numismatic Notes, VII: Mithridates IV. Bulletin of the New York Academy of Medicine 48(8): 1059-1064. Kaberopoulos, D., Karamanou, M. and Androutsos, G. (2012), The art of medicine: The theriac in antiquity. The Lancet 379: 1942-1943. Karamanou, M., Androutsos, G., Hayes, A. W. and Tsatsakis, A. (2018), Toxicology in the Borgias period: The mystery of Cantarella poison. Toxicology Research and Application 2: 1-3. Valle, G., Stanislao, M., Facciorusso, A., Carmignani, M. and Volpe, A. R. (2010), Mithridates VI Eupator, father of the empirical toxicology. Clinical Toxicology 47(5): 433. Author unknown, Wikipedia (date unknown), Antiochus III the Great (online) (Accessed 28/07/2023). Author unknown, Wikipedia (date unknown), Demetrius I Soter (online) (Accessed 28/07/2023). Author unknown, Wikipedia (date unknown), Laodice IV (online) (Accessed 28/07/2023). Author unknown, Wikipedia (date unknown), Laodice VI (online) (Accessed 28/07/2023). Author unknown, Wikipedia (date unknown), Mithridates VI Eupator (online) (Accessed 29/07/2023). Author unknown, Wikipedia (date unknown), Seleucus II Callinicus (online) (Accessed 28/07/2023).

In this episode Ryan is joined by a guest panel (Dr. Grant Comstock MD, Dr. Joshua Trebach MD, Dr. Emily Kiernan DO, and Dr Frank Paloucek PharmD, DABAT) to review nine of the most interesting or clinically impactful research abstracts that were presented at the 2023 North American Congress of Clinical Toxicology (NACCT) in Montreal Canada. If you didn't get a chance to read all 363 research abstracts from some of Toxicology's best and brightest this year, tune in for a high yield review as well as clinical a break down of the studies and their relevance from the expert panel.  Check the show notes for a link to the published abstracts and the list of all studies discussed in the showAbstracts available here10:40- Abstract 1 (PDF #225) Methotrexate toxicity in the setting of therapeutic error, a multicenter retrospective reviewLead author: Andrew Chambers24:12- Abstract #2 (PDF #251) Oleander seeds in candlenut weight loss product strike againLead author: Masha Yemets31:16- Abstract #3 (PDF #2) Efficacy of sodium tetrathionate when administered intramuscularly for the treatment of acute oral cyanide toxicity in a swine model (Sus scrofa)Lead author: Brooke Lajeunesse39:45- Abstract #4 (PDF #10) Is HOUR enough after out-of hospital naloxone for opioid overdose? Prospective preliminary data from real-world implementation of the modified St. Paul's early discharge ruleLead author: Stephen Douglas49:05- Abstract #5- Poster titles at NACCT 2013–2022: is NACCT experiencing a pun-demic?Lead author: Dayne Laskey52:40- Rivastigmine discussionLead author: none58:40- Abstract #6 (PDF #5)  Randomized controlled trial of ANEB-001 as an antidote for acute cannabinoid intoxication in healthy adultsLead author: Andrew Monte1:08:00- Abstract #7 (PDF#216) Successful use of expired physostigmine to treat anticholinergic delirium in a pediatric patientLead author: Bryan Hayes01:20:00- Abstract #8 (PDF #202) Enough negativity? Clinically significant salicylism with first detectable concentration twelve hours )post-ingestionLead author: Stacey Bangh01:25:24 - Abstract #9 (PDF #267) High sensitivity troponin is frequently elevated after carbon monoxide exposureLead author: Abdullatif Aloumi

In 2022, 75% of overdose deaths involved illicit fentanyl, a highly potent opioid. In this episode, Dr. Philip Chan is joined by Bryan Volpe, a Drug Intelligence Officer at The New England High Intensity Drug Trafficking Area and Dr. Louis Marchetti, Chief of Operations at the Center for Clinical Toxicology and Laboratory Support, at the Rhode Island State Health Laboratories for a  look at what's being done to keep Rhode Islanders safe from a deadly drug supply.  

Dengue CDC. Clinical assessment. Centers for Disease Control and Prevention. Cdc.gov. https://www.cdc.gov/dengue/training/cme/ccm/page73112.html CDC. Dengue. Centers for Disease Control and Prevention. Published August 15, 2023. https://www.cdc.gov/dengue/index.html Rigby J. First Pill for Dengue Shows Promise in Human Challenge Trial. Medscape: Emergency Medicine. Published October 23, 2023. https://www.medscape.com/s/viewarticle/997558?ecd=wnlscitech231101MSCPEDIT_etid6007373&uac=255848DR&impID=6007373 Schnirring L. California confirms 2nd local dengue case. Center for infectious disease research and policy. University of Minnesota. Umn.edu. Published November 2, 2023. https://www.cidrap.umn.edu/dengue/california-confirms-2nd-local-dengue-case Penis Pain Lizza E. Peyronie Disease. Medscape.com. Published August 17, 2023. https://emedicine.medscape.com/article/456574-overview Malloy M, Sinert R. Dysuria and Discharge After a New Sexual Partner. Medscape. Published November 20, 2023. https://reference.medscape.com/viewarticle/847159 Promethazine 2018-2019 Targeted Medication Safety Best Practices for Hospitals. Ismp.org. https://www.ismp.org/sites/default/files/attachments/2019-01/TMSBP-for-Hospitalsv2.pdf Drug Shortage Detail: Promethazine Injection. Ashp.org. Updated November 21, 2023. https://www.ashp.org/drug-shortages/current-shortages/drug-shortage-detail.aspx?id=872 Fass O. Antiemetics and QT prolongation. Clinicalcorrelations.org. Published January 15, 2021. https://www.clinicalcorrelations.org/2021/01/15/antiemetics-and-qt-prolongation/ Ozempic Korte C. Ozempic side effects could lead to hospitalization — and doctors warn that long-term impacts remain unknown. CBS News. Published June 10, 2023. https://www.cbsnews.com/news/ozempic-side-effects-weight-loss-drugs-wegovy-mounjaro-doctors-warn/ Krishnan L, Dhatariya K, Gerontitis D. No clinical harm from a massive exenatide overdose – a short report. Clin Toxicol (Phila). Clinical Toxicology. Published December 11, 2012. https://www.tandfonline.com/doi/pdf/10.3109/15563650.2012.752495 MedWatch: The FDA Safety Information and Adverse Event Reporting Program. FDA: U.S. Food and Drug Administration. Published September 15, 2022. https://www.fda.gov/medwatch Nakanishi R, Hirose T, Tamura Y, et.al. Attempted suicide with liraglutide overdose did not induce hypoglycemia. Diabetes Research and Clinical Practice. Diabetesresearchclinicalpractice.com. Published November 12, 2012. https://www.diabetesresearchclinicalpractice.com/article/S0168-8227(12)00384-1/fulltext Ozempic® (semaglutide) injection for Type 2 Diabetes. Ozempic.com. https://www.ozempic.com/ Hearing Loss Ahmed OH, Gallant SC, Ruiz R, Wang B, Shapiro WH, Voigt EP. Validity of the Hum Test, a Simple and Reliable Alternative to the Weber Test. Ann Otol Rhinol Laryngol. NIH: National Library of Medicine: National Center for Biotechnology Information. Published June 2018. https://pubmed.ncbi.nlm.nih.gov/29776326/#:~:text=Results%3A%20When%20examining%20the%20ability,respectively%2C%20with%20low%20pitched%20humming. Clinical Practice Guideline: Sudden Hearing Loss (Update). American Academy of Otolaryngology – Head and Neck Surgery. Entnet.org. https://www.entnet.org/quality-practice/quality-products/clinical-practice-guidelines/sudden-hearing-loss-update/ Hearing loss in adults: assessment and management. National Guideline Centre (UK). Immediate, Urgent and Routine Referral. National Institute for Health and Care Excellence; 2018. NIH: National Library of Medicine: National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK536553/#:~:text=If%20the%20hearing%20loss%20developed,service%20or%20an%20emergency%20department. Mroz M. Do you know the three main types of hearing loss? Healthy Hearing. Published April 17, 2014. https://www.healthyhearing.com/help/hearing-loss/types Recurring Sources Center for Medical Education. Ccme.org. http://ccme.org The Proceduralist. theproceduralist.org. http://www.theproceduralist.org The Procedural Pause. Emergency Medicine News. lww.com. https://journals.lww.com/em-news/blog/theproceduralpause/pages/default.aspx The Skeptics Guide to Emergency Medicine. thesgem.com. http://www.thesgem.com Be sure to keep tuning in for more great prizes and fun trivia questions! Once you hear the question, please email us your guesses at 2viewcast@gmail.com and tell us who you want to give a shout-out to. Be sure to listen in and see what we have to share!

In this episode, Ryan dives into cutting-edge research on the treatment of acetaminophen (APAP) overdose, featuring interviews with authors of several key abstracts from the North American Congress of Clinical Toxicology (NACCT) in Montreal Canada (Abstracts and posters available in the show notes). We get first looks insights into research evaluating the impact of fomepizole high risk acetaminophen overdose, as well as who gets fomepizole for acetaminophen overdose and dies. Then we evaluate the effectiveness of standard N-acetylcysteine (NAC) treatment in high risk patients and high dose NAC in high risk patients. Join us for an insightful discussion on these advancements that are reshaping the management of APAP toxicity. Guests include Dr. Masha Yemets PharmD, Dr. Molly Stott PharmD, Dr. Alexandru Ulici PharmD, and Dr. Michael Moss MD.   Link to published abstracts(First guest) Abstract #126 Characterizing fomepizole use in acetaminophen deaths reported to US poison centers- Dr. Yemets(Second guest) Abstract #125 Clinical impact of fomepizole as an adjunct therapy in massive acetaminophen overdose- Dr. Stott(Third guest) Abstract #131 Comparison of low-risk and high risk acetaminophen ingestions using the standard prescott protocol of intravenous N-acetylcysteine- Dr. Ulici(Fourth guest) Abstract #130 High-risk acetaminophen overdose outcomes after treatment with standard dose vs. increased dose N-acetylcysteine- Dr. MossOther studies discussed regarding NAC dosingATOM 2 Angela ChiewOutcomes of massive APAP treated with regular NAC (Virginia group, lead author Dr. Downes)

Mini episode- High-yield over view of Management of Acetaminophen Poisoning in the US and Canada Consensus Statement In this Ryan sits down with Dr. Richard Dart MD, PhD. He is the lead author of the recently released "Management of Acetaminophen Poisoning in the US and Canada Consensus Statement" from the American Academy of Clinical Toxicology, American College of Medical Toxicology, Americans Poisons Centers, and the Canadian Association of Poison Centers. Listen to be informed on the most recent treatment recommendations.  They dive in to the definitions established by the guideline and notable treatment recommendations, dissecting the ratinonale for each desiscion point and how to apply the guidelines. A mini episode was released along side this episode that is a high yield review of major treatment recommendations and definitions estabilished by the consensus statement.  Links :Mini episode- High-yield over view of Management of Acetaminophen Poisoning in the US and Canada Consensus Statement Guidelines https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2808062Definitions made by the guidelineAcute ingestionAny overdose taken with 24 hours periodOverdose "dose" not defined>7.5 g in 24 h was criteria for Rumack Matthew nomogramConsensus statementAdult overdose at 10g/d or 200 mg/kg/d in 48 hours) AND signs of APAP toxicity (vomiting, RUQ abd pain, AMS)Treat if APAP >20 ug/ml OR AST/ALT elevatedAcuteNon-detectable [APAP] between 2 and 4 hours excludes ingestionGive SDAC w/in 4 hours (something I've been a proponent of since ATOM2)TreatStart treatment with NAC if unable to plot on nomogram by 8 hoursNAC dose“Higher dose” NAC (undefined) for high risk ingestionMinimum NAC regimen should include 300 mg/kg orally or within 20-24 hoursCAP NAC dose at 100 kg (this was known with PO, but IV there was always some question since it delivers less overall)Unique scenariosLine crossersAPAP with anticholinergic or opioidIf 1st  concentration below treatment line repeat in 4-6 hoursAPAP Extended releaseIf 1st  concentration below treatment line @ 4-12 hours, repeat in 4-6 hoursDialysis-Dialyze If APAP >900 w/ AMS or acidosis.NAC IV rate during HD 12.5 mg/kg/hr minimum. No dose change for PO (not new but good reminders)Consult liver transplant for rapid AST/ALT inc w/ coagulopathy, AMS, or mulistytem organ failureThe addition of fomepizole to acetylcysteine in the treatment of serious acetaminophen ingestions has been proposed. The panel concluded that the data available did not support a standard recommendation. As for any complicated or serious acetaminophen poisoning, a PC or clinical toxicologist should be consulted.

This episode is a a high yield "just the facts" break down of the recently released "Management of Acetaminophen Poisoning in the US and Canada Consensus Statement" from the American Academy of Clinical Toxicology, American College of Medical Toxicology, Americans Poisons Centers, and the Canadian Association of Poison Centers. Listen to be informed on the most recent treatment recommendations. This was released alongside a full interview with the consensus statement corresponding author Dr. Richard Dart MD, PhD. Be sure to check out the full interview to hear it straight from the source! (link in show notes).Link to the guidelines:Full interview with consensus statement author Dr. Richard Darthttps://jamanetwork.com/journals/jamanetworkopen/fullarticle/2808062Definitions made by the guidelineAcute ingestion>7.5 g in 24 h per Rummack Matthew initial studies10 g/d or 200 mg/kg/day in 48 hHigh risk ingestionReported dose >30 grams OR[APAP] 2 x Rummack-Matthew nomogram treatment lineNAC stopping criteriaAPAP4 g x >48 hours) AND signs of APAP toxicity (vomiting, RUQ abd pain, AMS)Treat if APAP >20 ug/ml OR AST/ALT elevatedAcuteNon-detectable [APAP] between 2 and 4 hours excludes ingestionGive SDAC w/in 4 hours (something I've been a proponent of since ATOM2)Start treatment with NAC if unable to plot on nomogram by 8 hoursNAC dose“Higher dose” NAC (undefined) for high risk ingestionMinimum NAC regimen should include 300 mg/kg orally or within 20-24 hoursCAP NAC dose at 100 kg (this was known with PO, but IV there was always some question since it delivers less overall)Unique scenariosLine crossersAPAP with anticholinergic or opioidIf 1st  concentration below treatment line repeat in 4-6 hoursAPAP Extended releaseIf 1st  concentration below treatment line @ 4-12 hours, repeat in 4-6 hoursDialysis-Dialyze If APAP >900 w/ AMS or acidosis.NAC IV rate during HD 12.5 mg/kg/hr minimum. No dose change for PO (not new but good reminders)Consult liver transplant for rapid AST/ALT inc w/ coagulopathy, AMS, or mulistytem organ failureThe addition of fomepizole to acetylcysteine in the treatment of serious acetaminophen ingestions has been proposed. The panel concluded that the data available did not support a standard recommendation. As for any complicated or serious acetaminophen poisoning, a PC or clinical toxicologist should be consulted.

As Sarah delves deeper into Cassandra's history, particularly into her past relationships, she discovers a pattern of financial abuse, and something more sinister – deliberate and repeated poisoning.If you liked what you heard today, give the podcast a like, review, and subscribe. Follow F**k That on Facebook, TikTok and Twitter @fthatpodInstagram @fthat_podSupport the podcast on Patreon for exclusive and ad-free content @fthatpodThank you to this week's sources:Sarah's pages for Brandon:I HIGHLY recommend you like/follow. Sarah is such an amazing record keeper and is so thorough in investigating what happened to Brandon. Sarah is 100 times more of a detective than the “detective” that closed her son's case. Instagram - @brandons.voiceTikTok - @justiceforbrandonembryFacebook - Brandon's Voice – The Murder and Coverup of Brandon Embry Sign the petition:https://www.change.org/p/asheboro-police-department-to-get-brandon-embry-s-case-reopenedDocumentation Provided by Sarah: Asheboro Police Department Incident ReportSeptember 12th, 2019 Asheboro Police Department Records Request (88 pages) Crime scene photos Text exchanges between Sarah and Brandon Facebook Messenger exchanges between Sarah and Cassandra Hotel photos - Detroit work trip Generation Why Podcast Episode 433 – Brandon Embry John Philpinhttps://johnphilpin.com/ Murder She Told PodcastThe Mysterious Death of Brandon Embry Part 1 – 3 Central Maine Former Augusta man to serve 60 years for raping two boys https://www.centralmaine.com/2016/02/24/state-wants-65-year-sentence-for-augusta-man-convicted-of-child-rape/ WMTW News Maine man convicted of killing informant sentenced https://www.wmtw.com/article/maine-man-convicted-of-killing-informant-sentenced/3377225CDC - Ethylene Glycol: Systemic Agent https://www.cdc.gov/niosh/ershdb/emergencyresponsecard_29750031.html Hovda, K. E., Julsrud, J., ØvrebØ, S., BrØrs, O., & Jacobsen, D. (2011). Studies on ethylene glycol poisoning: One patient -- 154 admissions. Clinical Toxicology (15563650), 49(6), 478–484. https://doi-org.scsu.idm.oclc.org/10.3109/15563650.2011.590140 Corr, P., & Szólics, M. (2012). Neuroimaging findings in acute ethylene glycol poisoning. Journal of Medical Imaging & Radiation Oncology, 56(4), 442–444. https://doi-org.scsu.idm.oclc.org/10.1111/j.1754-9485.2012.02362.x Prinz, J., Böll, B., von Bergwelt-Baildon, M., Burst, V., Becker, J. U., Carvalho-Fiel, D., Shimabukuro-Vornhagen, A., & Kochanek, M. (2019). [Antifreeze poisoning : The case of a patient with repeated ethylene glycol poisoning]. Medizinische Klinik, Intensivmedizin Und Notfallmedizin, 114(2), 159–163. https://doi-org.scsu.idm.oclc.org/10.1007/s00063-018-0439-5

In this video I share the testimony of my student, a medical doctor, who used the information I taught her to STOP taking her allergy medications, which she used to take weekly, several times a week. Instead, she uses Orthomolecular Nutrition, to give her body the nutrients it needs to heal and prevent allergy attacks. I also talk about the amazing safety of vitamins and minerals, based on the 39th annual report from the American Association of Poison Control Centers which showed that vitamin and mineral supplements caused ZERO deaths, despite the FDA's constant warnings about how “dangerous” they are. I contrast this with the high death rate caused by iatrogenic errors, or death by the modern medical system. ZERO DEATHS FROM VITAMINS.ZERO DEATHS FROM MINERALS Supplement Safety Confirmed by America's Largest Database by Andrew W. Saul, Editor OMNS (Jan 23, 2023) The 39th annual report from the American Association of Poison Control Centers shows zero deaths from vitamins. Confirming data is in Table 22B, p 1613-1615, at the very end of the lengthy report published in Clinical Toxicology.[1] It is interesting that it is placed way back there where nary a news reporter is likely to see it. But there it is: no deaths, none whatsoever, from vitamin A, niacin, pyridoxine (B-6) or from any other B-vitamin. There were no deaths from vitamin C, vitamin D, or vitamin E. There were no deaths from multiple vitamins. There were no deaths from any vitamin at all. Furthermore, there were no fatalities from mineral supplements. Two fatalities from "Iron and Iron Salts" were clearly stated as not being due to supplemental iron (p 1607). No deaths from vitamins. No deaths from minerals. Want to bet this will never be on the evening news? Well, have you seen it there? And why not? This is of real importance to the public. After all, at least two-thirds of the U.S. population takes daily nutritional supplements. A Harris Poll indicated that for American adults, the number is 86%. [2] But let's just use the lower number. Should each of those people take only one single tablet daily, that still makes over 220,000,000 individual doses per day, for a total of well over 80 billion doses annually. Since many persons take far more than just one single vitamin tablet, actual consumption is considerably higher, and the safety of vitamin supplements is all the more remarkable. Throughout the entire year, coast to coast across the entire USA, there was not one single death from a vitamin or mineral supplement. If supplements are allegedly so "dangerous," as the FDA, the news media, and even some physicians still claim, then where are the bodies? (Andrew W. Saul is Editor-in-Chief of the Orthomolecular Medicine News Service, now in its 19th year of free publication. He is also a member of the Japanese College of Intravenous Therapy; the Orthomolecular Medicine Hall of Fame; and is author or coauthor of twelve books. He has no financial connection whatsoever to the supplement or health products industry.) References: 1. Gummin DD, Mowry JB, Beuhler MC et al. (2022) 2021 Annual Report of the National Poison Data System (NPDS) from America's Poison Centers: 39th Annual Report, Clinical Toxicology, 60:12, 1381-1643, DOI: 10.1080/15563650.2022.2132768 https://doi.org/10.1080/15563650.2022.2132768 2. https://osteopathic.org/2019/01/16/poll-finds-86-of-americans-take-vitamins-or-supplements-yet-only-21-have-a-confirmed-nutritional-deficiency/ --- Send in a voice message: https://podcasters.spotify.com/pod/show/arukah/message

All published abstracts can be found here AbstractsCategory 1: Amlodipine VasoplegiaAbstract 1: Vasodilation in patients with calcium channel blocker poisoning treated with high dose insulin: a comparison of amlodipine versus non-dihydropyridinesStudy of HDI on propranolol poisoned pigsStudy of Minnesota HDI protocolAbstract 2: Amlodipine anxiety: a 10-year review of amlodipine associated fatalitiesAbstract 3: Extracorporeal membrane oxygenation utilization for vasoplegic shock due to pediatric toxic ingestionsData of ECMO in poisoningCategory 2: XylazineAbstract 4: “Tranq dope” opioid overdose: clinical outcomes for emergency department patients with illicit opioid overdose adulterated with xylazineCategory 3: Case Reports with Terrifying Clinical ImplicationsAbstract 5: Recovery after poly-drug overdose despite blood flow imaging demonstrating no brain perfusionAbstract 6: Challenges in diagnosing an environmental cause of recurrent methemoglobinemiaAbstract 7: Acute thiamine deficiency as a complication of insulin euglycemic therapy for an amlodipine overdoseCategory 4: Comparative evidence, Prognostication, and TriageAbstract 8: Utility of pre four-hour iron concentration in predicting toxicologyAbstract 9: Andexanet alfa vs 4-factor prothrombin complex concentrate for intracranial hemorrhage at a level I trauma hospitalCategory 5: Rapid ReviewAbstract 10: Fentanyl and fentanyl analogue exposure among emergency personnel and first responders: a systematic reviewAbstract 11: Significance of falsely low creatinine values in diagnosing massive acetaminophen ingestionAbstract 12: Large dose intentional ciprofloxacin ingestion associated with false-positive urine immunoassay for oxycodone and fentanylAbstract 13: Don't make it a double?: a 20- year review of supratherapeutic amlodipine ingestions while on chronic therapyAbstract 14: Evaluation of pediatric lisdexamfetamine exposures reported to a statewide poison control systemAbstract 15: An assessment of the reliability of stated quantity in acute acetaminophen overdoses reported to a regional poison center

In this episode of the podcast, we discuss the field of clinical toxicology with Professor Michael Eddleston. We chat about his journey through medical school - interspersed with work abroad and a PhD - as well as his academic career and research interest in pesticide poisoning in rural Asia. This a really interesting episode for anyone who hopes to pursue an academic career alongside their clinical work.

December 24, 2020 — The synthetic opioid fentanyl is a huge problem in the US right now, according to Sheriff Matt Kendall, who sees some of the social effects first-hand. “It is the biggest problem,” he says, because fentanyl is so much cheaper than methamphetamine or heroin to make. “I believe there’s more fentanyl on the streets right now than heroin,” he added. “This is going to be the new epidemic.” It’s a scary substance. In 2018, the CDC, in partnership with the National Institute of Occupational Safety and Health, put out a video from police body cams that purported to show police officers in Virginia being accidentally exposed to fentanyl. Closer to home, the sheriff reported earlier this month that a deputy at the jail had accidentally been exposed to the drug while cleaning a cell where an inmate had suffered a severe overdose from fentanyl that had somehow been smuggled in. The deputy started feeling woozy, received a dose of Narcan, and was taken to the hospital for observation. He was wearing PPE, including a mask, gloves, and long sleeves. He was also wearing eyeglasses, but not protective goggles. Kendall says it’s impossible to be exposed to fentanyl through the skin, but he thinks the deputy may have been affected by powder that got into a cut on his skin, into his eyes, or by inhaling it. But Dr. Rachel Winograd, a clinical psychologist who works as an associate research professor at the University of Missouri St. Louis, the Missouri Institute of Mental Health, says that sounds impossible. Her work revolves around the role of opioids in what she and others in the field call “the worsening poisoning crisis.” She’s especially concerned with effective, equitable treatments for addiction. In August of this year, she led a team that researched and published an article on misinformation about the risks of accidental fentanyl contact. ”I suppose if you walked into a cloud of fentanyl dust in the air, then technically when you breathe it in, it would get into your system,” she conceded. But typically, getting affected by the drug requires something much more intentional. Users inject it, snort it, insert it rectally, or apply a fentanyl patch, which last is the most common legal use. Kendall says the substance that was found in the inmate’s cell, including on the bed sheets, had preliminary tests done on it before it was shipped off to the California Department of Justice for a full analysis, which has not come back yet. Any toxicology tests that may have been performed on the deputy would be privileged medical information. “You’ll notice that in all the anecdotal reports and accounts of first responders falling ill to overdose from incidental fentanyl exposure, there are zero reports of toxicology that match the anecdote,” Winograd says. “It’s not what’s happening. Something else might be happening, maybe more related to some panic, or nerves, fear, anxiety...but it’s not an overdose.” In a 2017 position paper on incidental fentanyl exposure to first responders, the American College of Medical Toxicology and the American Academy of Clinical Toxicology agree that “the risk of clinically significant exposure to emergency responders is extremely low.” The paper goes on to say that, while terrorists in Russia killed 125 people with a weaponized aerosolized carfentanil mixture, an unprotected individual exposed to “the highest airborne concentration encountered by workers” would require 200 minutes of such exposure to reach a dangerous dose. Absorption of liquid fentanyl does increase with broken skin. The paper cites a veterinarian who was quickly affected after being splashed in the eyes and mouth with a dart containing a mixture of carfentanil and xylazine, but says that facial contact with liquid or powder opioids is unlikely. Winograd’s team has started incorporating accurate information about the hazards of incidental exposure, or lack thereof, into a law enforcement training program. She says lives could be on the line. “By the end of our training, we had pretty overwhelming results that we were able to bust this myth in the minds of those who attended our trainings,” she reported. “And the idea there, why that matters, is that if first responders are really scared that they are going to overdose themselves, or put themselves in harm’s way when they go to save someone’s life from an overdose, then that’s going to deter them from doing it...or it will at least slow them down if they feel like they need to put on a bunch of protective equipment...if you take an extra two minutes to don a bunch of PPE, that could cost someone their life.”

Is Corona still about our well-being? More and more people are questioning this because of the collateral damage to health alone is becoming overwhelming. A Sars-Cov-2 vaccination that has been promised makes us look again at this point: a technology that has never been approved before, a genetic intervention in humans, the so-called mRNA vaccination. About four months ago, the immunologist and toxicologist Prof. Stefan Hockertz was our interlocutor on this subject. At that time he was not at all well, he warned against a million times willful bodily harm by immature vaccines that have not been adequately tested according to our standard developed to this day. Today, for example, the companies Biontech and Curevac are promising their vaccination candidates very soon. What has Prof. Hockertz been able to find out to this day about the mechanisms of action, the study situation and the approval formalities? Now listen to an UPDATE on the corona vaccination. It starts very basically. Dr. Stefan Hockertz was director and professor of the Institute for Experimental and Clinical Toxicology at the University Medical Center Hamburg Eppendorf from 2003 to theend of 2004. Before that, he was a member of the board of directors of the Fraunhofer Institute for Toxicology and Environmental Medicine in Hamburg from 1995 to 2002. From 1986 to 2001 he was a researcher at the Fraunhofer Society in Hanover. Hockertz completed his first training as a biologist in 1985. Prof. Stefan W. Hockertz is appointed eurotox-registered toxicologist. He is also Dr. rer. nat. in biology at the University of Hanover, qualified as a professor in toxicology and pharmacology at the University of Hamburg, and professor for molecular immunotoxicology at the University Medical Center Hamburg Eppendorf. Today he is managing partner of tpi consult GmbH, one of the leading toxicological and pharmacological technology consultancies in Europe. First published in German on November 28, 2020 Translation and speaker: John JJ Jones Interview: Eva Schmidt The manuscript of the interview can be found on our website at: www.radiomuenchen.net

Immune to SARS-COV-2 – finally – thanks to an emergency vaccination. That is exactly what large parts of the population – and the government – want right now. Pharmaceutical companies are being given considerable support to advance the goal of a corona vaccination as quickly as possible. But how quickly is ethically justifiable? How many risks are being hidden because of the speed of development? Professor STEFAN HOCKERTZ, a biologist, pharmacologist and toxicologist, points out a number of unanswered questions and warns that millions of people will intentionally submit themselves to bodily harm if these questions are not answered ahead of time. Dr. Stefan Hockertz was director and professor of the Institute for Experimental and Clinical Toxicology at the University Medical Center Hamburg Eppendorf from 2003 to theend of 2004. Before that, he was a member of the board of directors of the Fraunhofer Institute for Toxicology and Environmental Medicine in Hamburg from 1995 to 2002. From 1986 to 2001 he was a researcher at the Fraunhofer Society in Hanover. Hockertz completed his first training as a biologist in 1985. Prof. Stefan W. Hockertz is appointed eurotox-registered toxicologist. He is also Dr. rer. nat. in biology at the University of Hanover, qualified as a professor in toxicology and pharmacology at the University of Hamburg, and professor for molecular immunotoxicology at the University Medical Center Hamburg Eppendorf. Today he is managing partner of tpi consult GmbH, one of the leading toxicological and pharmacological technology consultancies in Europe. First published in German on July 17, 2020 Translation and speaker: John JJ Jones Interview: Eva Schmidt The manuscript of the interview can be found on our website at: www.radiomuenchen.net/podcast-archiv…erletzung.html

PNM#11 - Jami Johnson Jami Johnson is a Medical Science Liaison for BTG Specialty Pharmaceuticals and an Adjunct Assistant Professor at the University of Oklahoma College of Pharmacy. Prior to her move to industry, she was the Assistant Managing Director of the Oklahoma Center for Poison and Drug Information. She completed undergraduate coursework at the University of Oklahoma in Norman prior to completing the Doctorate of Pharmacy Program at the University of Oklahoma College of Pharmacy. Dr. Johnson worked as a Poison Information Provider at the OCPDI while completing her PharmD, which initially sparked her interest in toxicology. After graduation, she completed the Clinical Toxicology and Emergency Medicine Fellowship Program at UFHealth-Jacksonville and the Florida Poison Information Center-Jacksonville. Upon completion of her fellowship, she obtained certification as a Diplomate of the American Board of Applied Toxicology. When she isn't MSLing, she enjoys donating her time to various professional organizations, most recently joining the ABAT NACCT 2019 Symposium committee and participating in AACT's Clinical Toxicology Recommendations Collaborative Activated Charcoal project on the systematic review committee and clinical recommendations panel. She is dedicated to continued professional improvement and growth, mostly recently joining the OU Health Sciences Center's 2019 Leadership Council. Her professional interests include critical care with an emphasis on cardiotoxicity, and natural toxins, especially venomous snakes. Her personal interests include avoiding the aforementioned natural toxins in the wild and spending time with her friends and family. BOOMER SOONER! In this episode: Toxicology training for pharmacists - fellowship vs residency ABAT examination - becoming a DABAT Snakes, antivenom and all things toxicology! --- Support this podcast: https://anchor.fm/empharmd/support

Welcome To The MedFlashGo Podcast. This Is Your Daily 4 Minutes Or Less Rapid Review for medical students. Topics are based on medical board examinations including USMLE, COMLEX, And Shelf Exams. We release a new episode every weekday! In this question of the day, Sean asks students to determine a question regarding acid-base disturbances in aspirin toxicity. These questions are powered by MedFlashGo The First Voice-based interactive medical question bank currently available on Alexa. This tool allows medical students to study medical topics and be interactively tested without the use of a screen. You can study on your couch, in your car, and on the move without the use of a screen. To get access to the free audio-interactive question bank, click here or go to your Alexa application and search medflashgo In the skills section. To learn more details go to medflashgo.com and check out our frequently asked questions section. Please know that these questions were creatively designed by medical students and physicians for the purpose of education and do not replace health information given from your health professionals. We have tried our best to make sure the information is accurate please, so please let us know if you find any errors and we will be sure to correct them. --- Send in a voice message: https://anchor.fm/medflashgo/message

Gui Moura apresenta um caso suspeito de intoxicação para Fred, Pedro e João! Contamos com a presença do dr. Vinicius Machado do Emergências SIMM! Confere a página deles no Instagram em @emergencia.simm Ficou com alguma dúvida ou quer fazer uma crítica ou sugestão? Fala com a gente no Twitter ou Instagram em @tadeclinicagem ou através do e-mail tadeclinicagem@gmail.com MINUTAGEM Em breve REFERÊNCIAS 1. POHJOLA-SINTONEN, Sinikka et al. Identification of drugs ingested in acute poisoning: correlation of patient history with drug analyses. Therapeutic drug monitoring, v. 22, n. 6, p. 749-752, 2000. 2. THANACOODY, Ruben et al. Position paper update: whole bowel irrigation for gastrointestinal decontamination of overdose patients. Clinical Toxicology, v. 53, n. 1, p. 5-12, 2015. 3. BENSON, B. E. et al. Position paper update: gastric lavage for gastrointestinal decontamination. Clinical toxicology, v. 51, n. 3, p. 140-146, 2013. 4. Australian Resuscitation Council (ARC) and New Zealand Resuscitation Council (NZRC): Guideline on emergency management of a victim who has been poisoned (2011) - disponível em https://www.nzrc.org.nz/assets/Guidelines/First-Aid/guideline-9-5-1-july11.pdf 5. YATES, Christopher; F MANINI, Alex. Utility of the electrocardiogram in drug overdose and poisoning: theoretical considerations and clinical implications. Current cardiology reviews, v. 8, n. 2, p. 137-151, 2012. 6. KRAUT, Jeffrey A.; MULLINS, Michael E. Toxic alcohols. New England Journal of Medicine, v. 378, n. 3, p. 270-280, 2018.

We look at 5 recent publications in the field of toxicology.Blanckaert, P. et al. Report on a novel emerging class of highly potent benzimidazole NPS opioids: Chemical and in vitro functional characterization of isotonitazene. (2020) Drug Testing and Analysis. 12: 422-430Reinstadler, V. et al. A validated workflow for drug detection in oral fluid by non-targeted liquid chromatography-tandem mass spectrometry. (2019) Analytical and Bioanalytical Chemistry. 411:867-876Benaglia, L. et al. Testing wastewater from a music festival in Switzerland to assess illicit drug use. (2020) Forensic Science International. 309:1-8Munoz-Munoz, A. et al. Characterization of an Amphetamine Interference from Gabapentin in an LC–HRMS Method. (2020) Journal of Analytical Toxicology. 44:36-40Darke, S. et al. Characteristics and circumstances of death related to gamma hydroxybutyrate (GHB). (2020) Clinical Toxicology. Published online 18 Feb 2020. Contact us at thetoxpod@sa.gov.auThe Toxpod is a production of Forensic Science SA and the South Australian Attorney General's Department. The opinions expressed by the hosts are their own and do not necessarily reflect the views of their employer.

Author: Aaron Lessen, MD Educational Pearls: A recent retrospective study looked capsaicin cream in treating cannabinoid hyperemesis syndrome in regards to length of stay, cost analysis, use of rescue therapies, and adverse events Results showed a trend towards reduced length of stay but did not reach statistical significance Use of opioids was reduced in the capsaicin group Capsaicin remains a potential treatment option in this often difficult disease References Samantha Wagner, Jason Hoppe, Matthew Zuckerman, Kerry Schwarz & Julie McLaughlin (2019) Efficacy and safety of topical capsaicin for cannabinoid hyperemesis syndrome in the emergency department, Clinical Toxicology, DOI: 10.1080/15563650.2019.1660783 Summarized by Jackson Roos, MS3 | Edited by Erik Verzemnieks, MD  

In 1495, a mysterious and deadly plague struck the city of Naples. Over the next 500 years, the medical attempts to understand and treat this new disease -- syphilis -- would mold and shape medicine in surprising ways. In this episode, Tony Breu and I will perform an historical and physiological biography of syphilis, covering the development of germ theory, epic poetry, mercury saunas, intentionally infecting patients with malaria, magic bullets, and lots and lots of experiments on poor rabbits. This presentation was performed live at the American College of Physicians’ national meeting in Philadelphia on April 11, 2019.   Sources (WARNING -- LONG LIST):   Swain, K. ‘Extraordinarily arduous and fraught with danger’: syphilis, Salvarsan, and general paresis of the insane. Lancet Psychiatry 5, (2018).   Kępa, M. et al. Analysis of mercury levels in historical bone material from syphilitic subjects – pilot studies (short report). Kępa Małgorzata 69, 367-377(11) (2012).   Forrai, J. Syphilis - Recognition, Description and Diagnosis. (2011). doi:10.5772/24205   Parascandola, J. From mercury to miracle drugs: syphilis therapy over the centuries. Pharm Hist 51, 14–23 (2009).   Eisler, C. Who Is Dürer’s ‘Syphilitic Man’? Perspect Biol Med 52, 48–60 (2009).   Rothschild, B. M. History of Syphilis. Clin Infect Dis 40, 1454–1463 (2005).   Schwartz, R. S. Paul Ehrlich’s Magic Bullets. New Engl J Medicine 350, 1079–1080 (2004).   Fee, E. The wages of sin. Lancet 354, SIV61 (1999).   O’Shea, J. ‘Two Minutes with Venus, Two Years with Mercury’-Mercury as an Antisyphilitic Chemotherapeutic Agent. J Roy Soc Med 83, 392–395 (1989).   Mahoney, J., Arnold, R., Sterner, B. L., Harris, A. & Zwally, M. Penicillin Treatment of Early Syphilis: II. Jama 251, 2005–2010 (1984).   Waugh, M. Role played by Italy in the history of syphilis. Sex Transm Infect 58, 92–95 (1982).   Thorburn, A. Fritz Richard Schaudinn, 1871-1906: protozoologist of syphilis. Sex Transm Infect 47, 459–461 (1971).   CROSBY, A. W. The Early History of Syphilis: A Reappraisal. Am Anthropol 71, 218–227 (1969).   Clark, E. G. & Danbolt, N. The Oslo study of the natural history of untreated syphilis An epidemiologic investigation based on a restudy of the Boeck-Bruusgaard material a review and appraisal. J Chron Dis 2, 311–344 (1955).   MUNGER, R. S. Guaiacum, the Holy Wood from the New World. J Hist Med All Sci IV, 196–229 (1949).   Thomas, E. & r, W. Rapid Treatment of Early Syphilis with Multiple Injections of Mapharsen. J Nerv Ment Dis 99, 88 (1944).   WIEDER, L., FOERSTER, O. & FOERSTER, H. MAPHARSEN IN THE TREATMENT OF SYPHILIS: FURTHER EXPERIENCES. Arch Dermatol Syph 35, 402–413 (1937).   THON, L. SHOULD THE INTERNIST KNOW SYPHILIS? J Amer Med Assoc 97, 994–996 (1931).   Sarton, G. The Earliest Printed Literature on Syphilis, being Ten Tractates from the Years 1495-1498. Karl Sudhoff , Charles Singer , Henry E. Sigerist. Isis 8, 351–354 (1926).   COLE, H., GERICKE, A. & SOLLMANN, T. THE TREATMENT OF SYPHILIS BY MERCURY INHALATIONS: HISTORY, METHOD AND RESULTS. Arch Dermatol Syph 5, 18–33 (1922).   Mason, U. Observation: Use and Abuse of Salvarsan. J Natl Med Assoc 3, 340–3 (1911).   Fleming, A. & Colebrook, L. ON THE USE OF SALVARSAN IN THE TREATMENT OF SYPHILIS. Lancet 177, 1631–1634 (1911).   Evans, A. The Treatment of Syphilis by Salvarsan (Dioxy-diamido-arseno-benzol). Brit Med J 1, 617 (1911).   Boeck, W. History, Theory and Practice of Syphilisation. New Engl J Medicine 73, 20–25 (1865).   Veale, H. Remarks on Syphilis and Its Treatment. Edinb Medical J 10, 10–26 (1864).   LaFond RE and Lukehart SA, Biological Basis for Syphilis. Clinical Microbiology Reviews 2006.   Secher L et al, Treponema pallidum in peripheral nerve tissue of syphilitic chancres. Acta dermato-venereologica 1982.  Hollander DH, Turner TB, The role of temperature in experimental treponemal infection. American journal of syphilis, gonorrhea, and venereal diseases, 1954   Eagle H, et al. The effect of hyperpyrexia on the therapeutic efficacy of penicillin in experimental syphilis. American journal of syphilis, gonorrhea, and venereal diseases, 1947.   Kampmeier RH, Syphilis therapy: an historical perspective. Journal of the American Venereal Disease Association 1976.   Pachner AR, Spirochetal Diseases of the CNS. Neurologic clinics, 1986.   Sell S et al, Experimental syphilitic orchitis in rabbits: ultrastructural appearance of Treponema pallidum during phagocytosis and dissolution by macrophages in vivo. Laboratory investigation; a journal of technical methods and pathology, 1982.   Taylor SH, Diuretics in cardiovascular therapy. Perusing the past, practising in the present, preparing for the future. Zeitschrift für Kardiologie, 1985.   Ovchinnikov NM, [Treponema pallidum in peripheral nerves of rabbit syphiloma]. Vestnik dermatologii i venerologii, 1975.   Cheek DB, Wu F, The Effect of Calomel on Plasma Epinephrine in the Rat and the Relationship to Mechanisms in Pink Disease, Archives of Disease in Childhood, 1959   Vogl A, The discovery of the organic mercurial diuretics, American Heart Journal, 1950   Schwemlein GX et al, Penicillin and fever therapy in early syphilis, Journal of the American Medical Association, 1948.   Stringham JS, On the Diuretic Effects of Mercury in a Case of Syphilis. The Medical and physical journal, 1807   Evanson RL et al, Effect of mercurial diuretics on tubular sodium and potassium transport in the dog. The American journal of physiology, 1972   Sell S and Salman J, Demonstration of Treponema pallidum in Axons of Cutaneous Nerves in Experimental Chancres of Rabbits, Sexually Transmitted Diseases, 1992   Penn CW, Avoidance of Host Defences by Treponema pallidum in Situ and on Extraction from Infected Rabbit Testes, Microbiology 1981.   Beutler B and Munford RS, Tumor Necrosis Factor and the Jarisch–Herxheimer Reaction, The New England Journal of Medicine 1996.   Radolf JD et al, Treponema pallidum: doing a remarkable job with what it's got. Trends in Microbiology, 1999   Tight RR, Perkins RL, Treponema pallidum infection in subcutaneous polyethylene chambers in rabbits. Infection and immunity, 1976   Salazar JC et al, Treponema pallidum Elicits Innate and Adaptive Cellular Immune Responses in Skin and Blood during Secondary Syphilis: A Flow-Cytometric Analysis. The Journal of Infectious Diseases, 2007   Azevedo BF et al, Toxic Effects of Mercury on the Cardiovascular and Central Nervous Systems. Journal of Biomedicine and Biotechnology 2012,   Clarkson TW and Magos L, The Toxicology of Mercury and Its Chemical Compounds, Critical Reviews in Toxicology 2008.   Fitzgerald TJ, The Th1/Th2-like switch in syphilitic infection: is it detrimental? Infection and immunity, 1992   Batterman RC et al, THE SUBCUTANEOUS ADMINISTRATION OF MERCAPTOMERIN (THIOMERIN®): Effective Mercurial Diuretic for the Treatment of Congestive Heart Failure. Journal of the American Medical Association, 1949   Batterman RC, The status of mercurial diuretics for the treatment of congestive heart failure. American Heart Journal, 1951   Bleich HL et al, The Role of Regional Body Temperature in the Pathogenesis of Disease, The New England Journal of Medicine, 1981   Vander Veer JB et al, The Prolonged Use of an Oral Mercurial Diuretic in Ambulatory Patients with Congestive Heart Failure. Circulation 1950   Cox DL et al, The outer membrane, not a coat of host proteins, limits antigenicity of virulent Treponema pallidum. Infection and immunity, 1992.   Fildes P, The Mechanism of the Anti-bacterial Action of Mercury. Br J Exp Pathol, 1940   Clarkson TW, THE MECHANISM OF ACTION OF MERCURIAL DIURETICS IN RATS; THE METABOLISM OF 203Hg‐LABELLED CHLORMERODRIN. British Journal of Pharmacology and Chemotherapy, 1965   Engelkens HJ et al, The localisation of treponemes and characterisation of the inflammatory infiltrate in skin biopsies from patients with primary or secondary syphilis, or early infectious yaws. Genitourinary Medicine, 1993   Belum GR et al, The Jarisch–Herxheimer reaction: Revisited. Travel Medicine and Infectious Disease, 2013   Arando M et al, The Jarisch–Herxheimer reaction in syphilis: could molecular typing help to understand it better? Journal of the European Academy of Dermatology and Venereology, 2018.   Butler T, The Jarisch–Herxheimer Reaction After Antibiotic Treatment of Spirochetal Infections: A Review of Recent Cases and Our Understanding of Pathogenesis. The American Journal of Tropical Medicine and Hygiene, 2016   Carlson JA et al, The Immunopathobiology of Syphilis: The Manifestations and Course of Syphilis Are Determined by the Level of Delayed-Type Hypersensitivity. The American Journal of Dermatopathology 2011.   Aronson IK and Soltani K, The enigma of the pathogenesis of the Jarisch-Herxheimer reaction. The British Journal of Venereal Diseases, 1976   Sellato TJ et al, The Cutaneous Response in Humans to Treponema pallidum Lipoprotein Analogues Involves Cellular Elements of Both Innate and Adaptive Immunity, The Journal of Immunology 2001   Spiller HA, Rethinking mercury: the role of selenium in the pathophysiology of mercury toxicity. Clinical Toxicology 2017   Sell S et al, Reinfection of chancre-immune rabbits with Treponema pallidum. I. Light and immunofluorescence studies. The American journal of pathology 1985.    Grant SS and Hung DT, Persistent bacterial infections, antibiotic tolerance, and the oxidative stress response, Virulence 2013   Lant AF, Modern diuretics and the kidney. Journal of Clinical Pathology, 1981   Kamath SU et al, Mercury-based traditional herbo-metallic preparations: a toxicological perspective, Archives of Toxicology 2012.   Yeter et al, Mercury Promotes Catecholamines Which Potentiate Mercurial Autoimmunity and Vasodilation: Implications for Inositol 1,4,5-Triphosphate 3-Kinase C Susceptibility in Kawasaki Syndrome. Korean Circulation Journal 2013   Wöβmann W et al, Mercury intoxication presenting with hypertension and tachycardia. Archives of Disease in Childhood, 1999   Giacani L et al, Identification of the Treponema pallidum subsp. pallidum TP0092 (RpoE) Regulon and Its Implications for Pathogen Persistence in the Host and Syphilis Pathogenesis. Journal of Bacteriology 2013.   Edwards AM, From tooth to hoof: treponemes in tissue‐destructive diseases. Journal of Applied Microbiology, 2003   Wolgemuth CW, Flagellar motility of the pathogenic spirochetes. Seminars in Cell & Developmental Biology 2015.   Solomon HC and Kopp I, Fever Therapy. The New England Journal of Medicine 1937.   Rice KM et al, Environmental Mercury and Its Toxic Effects. Journal of Preventive Medicine and Public Health 2014.   Drusin LM, Electron microscopy of Treponema pallidum occurring in a human primary lesion. Journal of bacteriology 1969.   McNeely MC et al, Cutaneous secondary syphilis: Preliminary immunohistopathologic support for a role for immune complexes in lesion pathogenesis. Journal of the American Academy of Dermatology 1986.   Borenstein LA et al, Contribution of rabbit leukocyte defensins to the host response in experimental syphilis. Infection and immunity 1991.   Cabot RC et al, Case 51-1976 — Bicentennial CPC — Syphilis, Diarrhea and Death in the 1820's. The New England Journal of Medicine 1976.   Hobman JL and Crossman LC, Bacterial antimicrobial metal ion resistance. Journal of Medical Microbiology 2015   Gelpi A and Tucker JD, After Venus, mercury: syphilis treatment in the UK before Salvarsan. Sexually Transmitted Infections 2015.   MacHaffie et al, A study of the effectiveness of mercurial diuretics in treatment of cardiac decompensation. The American Journal of Cardiology 1958   Aberer W et al, Ammoniated mercury ointment: outdated but still in use. Contact Dermatitis 1990   Farhi D, Dupin N, Origins of syphilis and management in the immunocompetent patient: Facts and controversies. Clinics in Dermatology (2010) 28, 533–538   Frith J, “Syphilis – Its early history and Treatment until Penicillin and the Debate on its Origins,” Journal of Military and Veterans’ Health, 20(4), retrieved online at: http://jmvh.org/article/syphilis-its-early-history-and-treatment-until-penicillin-and-the-debate-on-its-origins/   Howes OD et al, “Julius Wagner-Jauregg, 1857-1940,” American Journal of Psychiatry, April 2009 Volume 166 Number 4, Volume 166, Issue 4, April, 2009, pp. 409-409.   Karamanou M et al, “Julius Wagner-Jauregg (1857-1940): Introducing fever therapy in the treatment of neurosyphilis.” Psychiatriki. 2013 Jul-Sep;24(3):208-12.   Simpson WM, “Artificial fever therapy of syphilis,” JAMA. 1935;105(26):2132-2140.   Tsay CJ, “Julius Wagner-Jauregg and the Legacy of Malarial Therapy for the Treatment of General Paresis of the Insane,” Yale J Biol Med. 2013;86(2): 245–254   Wagner-Jauregg J, “The history of malaria treatment of general paralysis.” Am J Psychiatry. 1946;02: 577-582   Shafer JK et al, Untreated syphilis in the male Negro: A prospective study of the effect on life expectancy. Public Health Rep. 1954 Jul; 69(7): 684–690.   Abara WE et al, Syphilis Trends among Men Who Have Sex with Men in the United States and Western Europe: A Systematic Review of Trend Studies Published between 2004 and 2015. PLoS One. 2016; 11(7): e0159309.   Nutton V, The Reception of Fracastoro's Theory of Contagion: The Seed That Fell among Thorns? Osiris, Vol. 6, Renaissance Medical Learning: Evolution of a Tradition (1990)   Tsaraklis A, Preventing syphilis in the 16th century: the distinguished Italian anatomist Gabriele Falloppio (1523-1562)  and the invention of the condom. Le Infezioni in Medicina, n. 4, 395-398, 2017.

Continuing with our recent theme of increased fire related inhalational risks with colder weather, MCHD Paramedic Podcast toxicology guru, Dr. Jerry Snow, joins us again to discuss cyanide poisoning. We’ll discuss ways to recognize cyanide toxicity and when to empirically treat. Combining this episode with our recent carbon monoxide podcast will make you razor sharp when you run on your next house fire. References: 1. Curry, Steven C., and Meghan B. Spyres. "Cyanide: hydrogen cyanide, inorganic cyanide salts, and nitriles." Critical care toxicology (2016): 1-21. 2. Purvis, M. V., et al. "Prehospital hydroxocobalamin for inhalation injury and cyanide toxicity in the United States-analysis of a database and survey of ems providers." Annals of burns and fire disasters 30.2 (2017): 126. 3. Kaita, Yasuhiko, et al. "Cyanide poisoning is a possible cause of cardiac arrest among fire victims, and empiric antidote treatment may improve outcomes." The American journal of emergency medicine 36.5 (2018): 851-853. 4. Parker-Cote, J. L., et al. "Challenges in the diagnosis of acute cyanide poisoning." Clinical Toxicology 56.7 (2018): 609-617.

Jeff:  Welcome back to Emplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta and we’ll be taking you through the September 2018 issue of Emergency Medicine Practice - Emergency Department Management of North American Snake envenomations. Nachi: Although this isn’t something we encountered too frequently – it does seem like I’ve been hearing more about snake bites in the recent months. Jeff: I actually flew someone just the other day because the local ED ran out of CroFab after an envenomation in Western PA. Nachi: Yeah, this is definitely more than “just a boards topic,” and it’s really important to know about in those rare circumstances. In terms of incidence, there are actually about 10,000 ED visits in the US for snake bites each year, and 1/3 of these involve venomous species. Jeff:  That’s a good teaser, so let’s start by recognizing this month’s team – the two authors, Dr. Sheikh, a medical toxicologist, and Patrick Leffers, a pharmD, and emergency medicine and clinical toxicology fellow. Both are at the University of Florida Jacksonville, and they reviewed a total of 120 articles from 2006-2017, in addition to reviews from both Cochrane and Dare. Nachi: And don’t forget our peer reviewers this month, Dr. Daniel Sessions, a medical toxicologist working at the South Texas Poison Center, and our very own editor-in-chief, Dr. Andy Jagoda, who is also Chair of the Department of Emergency Medicine at Mount Sinai in New York City. Jeff: What a team! But, let’s get back to the snakes. As some background, from 2006-2015 there were almost 66,000 reported snake exposures and 31 deaths from snake envenomation in the US.  Of course, this number likely underestimates the true total. Nachi: And there are two key subfamilies of venomous snakes to be aware of – the Crotalinae – or pit vipers – which includes rattlesnakes, copperheads, and water moccasins; and the Elapidae – of which you really only need to know about the coral snake. Jeff:  And while those are the only two NATIVE snake subfamilies to be acutely aware of, don’t forget that exotic snakes, which are shockingly popular pets -- they can also cause significant morbidity and mortality. Nachi:  Oh, and one other quick note before we get into the epidemiology – most of the recommendations this month come from expert opinion, as high quality RCTs are obviously difficult.  In addition, many of the studies were based in other countries, where the snakes, the anti-venoms and their availability, and the general healthcare systems are different from those that most of us work in. Jeff:  Unless we have listeners abroad? Do we have listeners in other countries? Nachi: Oh we definitely do... but we are going to be a bit biased towards US envenomation today. In any case, venomous snake bites occur most frequently in men aged 18 to 49 during warmer months with provoked bites occurring more frequently in the upper extremities and unprovoked bites in the lower extremities. Jeff:  In one study of poison center data from the last decade, nearly half of all victims of snake bites were victims of unknown type snakes.  However, of those that were known, copperheads were the most common, while rattlesnakes caused the most fatalities – 19 of 31 in this dataset. Nachi:  In a separate study of snake bites in the early 2000s, 32% of exposures were from venomous snakes and 59% of those resulted in admission. That’s remarkably high. Jeff:  Snake bite severity depends on several key factors: the amount of venom, the composition of the venom, the body size of the bite victim, the victim's clothing, the size of the bite, comorbid conditions, and the timing and quality of medical care the victim receives. Nachi:  To be a bit more specific - First, the amount of venom will depend on the species of snake, with variations even occurring within the same species.  Secondly, while there is a correlation between rattlesnake size and bite severity, there is much more at play.  Some snakes can even vary the amount of venom based on threat risk – with defensive bites having different profiles than bites to strike prey. Jeff: I found it pretty interesting that  an estimated 10-25% of pit viper bites are considered dry bites, that is, ones in which no venom is released. Nachi:  Right, this is just one reason why all victims shouldn’t immediately get anti-venom, but we’ll get there. Jeff:  We definitely will.  As we already stated – venom composition varies greatly.  Pit vipers produce a predominantly hemotoxic venom.  Systemic effects include tachycardia, tachypnea, hypotension, nausea, vomiting, weakness, and diaphoresis.  Neurotoxicity is rare and is usually due to inter-breeding between species. Nachi:  While rattlesnake bites are associated with higher morbidity and mortality, the more common copperhead bites typically only cause local tissue effects.  More serious systemic findings such as coagulopathy and respiratory failure have been reported though. Jeff:  So that’s a solid background to get us started.  Let’s talk about the individual snakes.  Why don’t you start with the crotalinae family – aka the pit vipers. Nachi:  Sure – the crotalinae includes rattlesnakes, cottonmouths (also known as water moccasins), and copperheads.  These make up the vast majority of reports to the poison centers.  They can be identified by their heat sensing pits located behind their nostrils (hence pit vipers).  As a general rule, you can also identify the venomous snakes by their triangular or spade-like head, elliptical pupils, and hollow retractable fangs. Jeff:  wait, so you want me to walk up to the snake and ask to see if their fangs retract… yea, no thanks. Nachi: Haha, of course not, I’m just giving you some of the general principles here. In contrast, non-venomous pit vipers have rounded heads, round pupils, a double row of vertical scales, and they lack fangs. Jeff: In terms of location, rattlesnakes are found in all states but Hawaii, and cottonmouths and copperheads are distributed mostly throughout the southern and southeastern states, with copperheads also extending further north, even into Massachusetts. Nachi: Moving on to the Elapidae –  there are 3 species of coral snakes, only two of which you need to know about, Micrurus fulvius fulvius or the eastern coral snake and Micrurus tener or the Texas coral snake.  Of the two, the eastern or Micrurus fulvius fulvius produces more potent venom. Jeff:  As you may have guessed by their names, the eastern coral snake is found in the southeastern united states, specifically, east of the Mississippi -- whereas the Texas coral snake lives west of the Mississippi. Nachi:  Venomous North American coral snakes can be recognized by the red and yellow bands around their bodies whereas their nonvenomous counterparts can be recognized by their characteristic black band between the red and yellow bands. I’m sure you’ve heard the popular mnemonic for this… Red touch yellow kill a fellow, red touch black, venom lack. Jeff:  I have heard that one, and it’s not a bad mnemonic. Just remember that this is more of a guideline than a rule, as it doesn’t always hold true. Nachi: Coral snakes also tend to chew rather than bite thanks to their short, fixed, hollow fangs.  Locally, bites can lead to muscle destruction thanks to a certain myotoxin.  Systemic signs of infection include nausea, vomiting, abdominal pain, and dizziness.  Jeff: The venom also contains a neurotoxin which can lead to diplopia, difficulty swallowing and speaking and generalized weakness. Nachi: Complicating matters even further, the onset of these symptoms may be delayed for many hours. Jeff:  Alright, so I think that about wraps up the background.  Let’s move on to the meat and potatoes of this article, starting with the differential. Nachi:  For differential this month, we are really focusing on differentiating a venomous snake from a non-venomous one. Jeff: Oh yeah, this is where you want us to ask the snake if it can retract its fangs, right? Nachi: Ha very funny – Although the type of snake may be obvious if the patient owns the snake, for most cases you see in the ED, the type of snake won’t be clear. Try to get a description of the snake and consider your local geography. Some patients may even bring the snake in with them. Jeff: yea, no thanks. As for prehospital care, it’s actually pretty interesting stuff as recommendations have changed many times.  You may have heard of the recommendations for incision / excision, use of venom extraction devices, tourniquets, chill methods and even electroshock therapy – well these methods are all OUT. Nachi:  Not only are they out, they actually worsen outcomes, so definitely don’t pursue any of them.  Instead,  since no treatment has been shown to improve outcome, you should prioritize prompt transport. Jeff: And while we definitely don’t want to encourage ill-advised attempts at capturing the snake, taking pictures at a distance may be helpful in identifying it.  Oh and the authors do note- pretty terrifying stuff coming up here so brace yourself - even if the snake is dead the bite reflex is still intact… Nachi: And that’s why I work in city hospitals… Jeff:  There’s also a bit of controversy here with regards to pressure immobilization, which is definitely something I thought we were supposed to do in the prehospital setting. Apparently in other countries, like Australia, prehospital providers frequently employ pressure immobilization – that is, wrapping bandages proximally up a splinted limb to impede lymphatic toxin spread. Nachi:  Right, but in Australia, not only are the snakes more venomous but the hospital transport distances are much longer, so, basically they sacrifice the limb to potentially save a life.  In the US, with our current indigenous snake population and the relatively short transport distances, this isn’t justified at all! Jeff:  Take home: based on the current literature, the American College of Medical Toxicology, other experts, and Drs. Sheikh and Leffers recommend against pressure immobilization in lieu of prompt patient transport to definitive treatment. Nachi:  Good to know – alright so now we have the patient in the emergency department, let’s begin ED care.  As always – IV, O2, Monitor including end tidal CO2 if you suspect a neurotoxic or exotic snake bite.  Of course, avoid using the affected limbs for vitals… Jeff: If not done already, remove any constrictive clothing or jewelry and mark the leading edge of pain, edema, and erythema both above and below the bite.  If EMS has placed bandages, leave them in place until antivenom and resuscitative equipment is ready. Nachi:  And definitely involve the poison control center or a medical toxicology service early as they are an amazing resource. It’s an easy number to remember.. 1-800-222-1222. If you just type “poison control center” into google, that number will come up immediately. Jeff: Hypotension should be treated with isotonic fluids and, as usual, anaphylaxis should be treated with the usual cocktail of antihistamines and epinephrine at first IM and then via infusion if refractory. Note that antivenom will NOT reverse anaphylaxis on its own. Nachi:  When eliciting a history, there are a number of important factors to look out for, including – time and location of the bite, description of the snake, tetanus status, comorbid conditions, medications and allergies, any systemic or neurologic symptoms, muscle cramps, perioral tingling or numbness, metallic taste, history of previous snakebites and any reactions to previous envenomation or antivenom treatment. Jeff: Moving on to the physical exam, when examining the wound, look specifically for local tissue effects which occur in over 90% of patients after pit viper envenomations.  In such cases, you would expect pain, erythema, swelling, tenderness, and myonecrosis beginning at the wound site and then spreading via the lymphatic system. Nachi:  In addition, specifically with pit viper envenomations, monitor the patient for possible compartment syndrome as the venom can lead to local tissue destruction, increased cell permeability, third spacing of fluids, and bleeding.  And remember that while the local compartment may be hypertensive, the patient may also have systemic hypotension. Jeff: Just to reiterate what I said before – hypotension may indicate severe anaphylaxis and its not necessarily just due to third spacing.  Regardless, the treatment is the same – epinephrine. Nachi:  Good point, but let’s focus on compartment syndrome for a minute.  True compartment syndrome is actually quite rare --- its really subcutaneous hypertension with preservation of otherwise normal compartment pressures that you’re most likely to see.  Compartment syndrome should therefore only be diagnosed by actual compartment measurements and not just the exam.  However, if you are dealing with compartments that can’t be measured, like in the fingers, you’re only choice is to be guided by the exam… Jeff:  Risk factors for compartment syndrome in the setting of a snake bite include envenomations in small children, involvement of digits, application of ice or cold packs, and delayed or inadequate antivenom administration. Nachi: In terms of respiratory effects of envenomations – they aren’t common.  Both bites to the head or neck and neurotoxin containing venom are potential causes. In the setting of respiratory failure, be prepared with advanced airway maneuvers like nasotracheal intubation or cricothyroidotomy. Antivenom will not reverse respiratory failure. Jeff: Neurologic effects may be present upon arrival but may also be delayed up to 12 hours in the case of eastern coral snake bites. Nachi: It’s noteworthy that in one study of almost 400 eastern coral snake exposures, the onset of systemic symptoms occurred on average 5.6 hours after the bite.  So definitely remember that repeat exams and observation will be tremendously important. Jeff:  The actual neurologic symptoms to look for depend on the snake.  Coral snake venom can produce a descending flaccid paralysis characterized by motor weakness, especially of the cranial nerves.  Similarly pit vipers, especially the Mojave rattlesnake, have also been associated with muscular weakness of the cranial nerves and even respiratory insufficiency. Nachi:  Pit viper envenomation can also lead to myokymia which is repetitive small muscle fasciculations.  Unfortunately, this myokymia may not respond to antivenom administration and myokymia of the chest well and torso can necessitate intubation in extreme cases.  Both myokymia and myonecrosis may lead to rhabdo in the case of significant envenomations. Jeff:  Pit viper envenomation can also cause hematologic effects.  Fibrinolysis and platelet consumption at the bit site can lead to decreased fibrinogen and thrombocytopenia.  In severe cases this can lead to systemic bleeding and even hemorrhagic shock.  Those on anticoagulants and anti-platelet agents are at increased risk. Nachi:  Dermal effects such as edema, ecchymosis, bullae, and bleeding are not uncommon, but up to 50% of coral snake bite victims may have none of these. Jeff:  And to round out this section – just be aware that rare effects such as osteonecrosis, ischemic stroke, massive PE, and septic shock have all been reported. Nachi: Let’s move on to diagnostic studies.  Most patients require a CBC, coags, and a fibrinogen concentration.  Those with systemic toxicity should also have their electroyltes, CPK, creatinine, glucose, and urine tested. Jeff:  And while the data is somewhat mixed, one study suggests that all patients with pit viper envenomations need their coags checked, not just those with severe symptoms as in one series nearly 90% of patients had missed coagulation abnormalities.  The clinical consequences of this aren’t clearly explained, so the authors don’t make a specific recommendation. Nachi:  In terms of imaging, a chest x-ray should be obtained in those with respiratory symptoms and ultrasound may even have an expanding role here for tracking edema, looking for fluid collections, and assessing deep muscle compartments and vascular flow. Jeff: I feel like we should get some entry music for every ultrasound reference because it seems to make its way into just about every episode. Nachi: What would it sound like? You bring this up every month. I’ll look into something for a future episode. If any of our listeners have a suggestion, shoot us an e-mail at emplify@ebmedicine.net. In terms of monitoring and observation, this is important, ALL patients with suspected pit viper envenomations should be observed for 8-12 hours with the leading edge marked every 15-30 minutes. Jeff:  In addition, serial diagnostic testing may also be needed as such changes will be used to guide treatment.  In those with systemic symptoms, lab testing will be required every 4-6 hours prior to discharge. Nachi:  Before we move onto treatment – let me quickly mention grading.  There is no universal grading system.  The snakebite severity score, the minimum-moderate-severe score, and grade 1-4 score which consider symptoms, exam findings, and lab abnormalities have all been studied.  None have been validated and none track changes, so the authors recommend relying on severity of symptoms and progression of symptoms to guide treatment. Jeff:  The crux of treatment for pit viper envenomations is with supportive care and anti-venom. Nachi:  FabAV or CroFab is the antivenom of choice for pit viper envenomations.  This antivenom is made from extracting the Fab portion of anti-venom antibodies from envenomated sheep and processing them with papain. Jeff:  Since the sheep are injected with venom from the western diamondback, eastern diamondback and Mojave rattlesnake as well as the cottonmouth, the FabAV is most effective against venom from these snakes, however it does have cross reactivity to other immunologically similar venoms. Nachi:  Indications for FabAV include a more than minimal local swelling, rapid progression of swelling, swelling crossing a major joint, evidence of hemotoxicity, signs of systemic toxicity including hemodynamic compromise, neuromuscular toxicity, and late or recurrent new-onset coagulopathy. Jeff:  Initially, dose FabAV as a bolus of 4-6 vials, IV.  With life threatening envenomations or those with cardiovascular collapse, double the starting dose to 8-12 vials.  The goal is arresting progression, improvement in coagulation abnormalities, and resolution of systemic symptoms. Nachi: Although FabAV will reduce the duration and severity of symptoms and lab abnormalities, it will not reverse tissue necrosis and may not reverse neurologic effects. Jeff:  Once the symptoms have been controlled after the bolus dose or a second bolus dose, maintenance dosing of 2 vials every 6 hours for 3 doses is recommended to prevent recurrence. Nachi:  So to reiterate.  4-6 vial bolus to start, doubled in severe cases and then 2 vials every 6 hours for 18 hours after that. Jeff:  You got it. Nachi:  And like most, maybe all medicines, there are side effects and contraindications to be aware of.  Hypersensitivity reactions and serum sickness to FabAV have been reported as 8% and 13% respectively.   Most are mild and can be treated with your standard bundle of steroids, antihistamines, fluids and epi. Jeff:  Risk factors for developing allergic reactions to FabAV include  a known allergy to papaya, papain, chymopapin, pineapple enzyme bromelain, and previous allergic reaction to FabAV. Nachi:  Although FabAV isn’t produced using copperhead venom, it may be effective in severe envenomations and in one study, FabAV reduced limb disability compared to placebo. Jeff:  Therefore, the authors very reasonably advise that you should use the patient’s clinical picture and individual factors rather than the snake species to guide your treatment. Nachi:  Interestingly, compartment syndrome should be treated with the initial 4-6 vial dose of antivenom and not necessarily a fasciotomy.  Fasciotomies have not been shown to improve outcomes and are reserved only for those failing anti-venom treatment. Jeff:  The reason for this is that antivenom may reduce tissue pressures obviating the need for fasciotomy.  In addition, fasciotomy wouldn’t affect muscle necrosis that is occurring so fascia removal really doesn’t solve anything. Nachi:  And just as anti-venom can be used to treat elevated compartment pressures, it can also be used to treat coagulopathy. Jeff:  Blood products should be used for those who are actively bleeding or severely anemic as venom does not discriminate and will destroy whatever blood it comes across. Nachi:  Recurrent and late onset coagulopathy after FabAV treatment has also been well described.   Although not exactly clear why, some speculate that it occurs for one of 4 reasons. 1) because the half life of FabAV is shorter than that of the venom, or 2) because the venom is initially stored in the soft tissues and then slowly released over time or 3) because the venom has a late onset component, or lastly, 4) there is delayed dissociation of the venom-antivenom complexes.  Regardless of the mechanism, late onset coagulopathy can be treated with FabAV. Jeff:  Luckily, bleeding associated with coagulopathy and bleeding associated with late onset coagulopathy are both extremely rare.   Nachi:  Moving on to coral snakes.  Coral snake bites should be treated with NACSA or North American Coral Snake anti-venom.  This antivenom halts or at least limits the progression of muscle paralysis and shortens the clinical course. Jeff:  Most experts recommend NACSA treatment with the first signs of systemic toxicity and not for all comers.  This recommendation is backed by the literature as in one observational study those treated with prophylactic NACSA did less favorably as compared to those who got it only after symptoms onset.  This is probably because NACSA doesn’t reverse neuromuscular weakness and only limits progression. Nachi:  And it’s not like you are just sitting by and watching while doing nothing – focus your initial treatment on wound care, pain control, and then observation for the development of systemic symptoms.  The exact length of observation will depend on the snake, but should be somewhere between 8 and 24h. Jeff:  As for dosing – the initial NACSA dose is 3-5 vials IV for both peds and adults with a repeat dose if the initial symptoms don’t improve. Nachi: Side effects and adverse reactions occur somewhere between 8-11% of the time with dermal reactions being most common and anaphylaxis being the most severe. Jeff: There is also one last anti-venom to be aware of – Coralmyn, for coral snake envenomations.  Coralmyn is a polyclonal antivenom F(ab’)2 coral snake antivenom, developed because the current lot of NACSA has technically expired although the date has been extended numerous times.  It’s currently in a phase 3 trial, so keep your eyes out. Nachi:  Other non-antivenom treatments that have been tested include acetylcholinesterase inhibitors and trypsin at the bite site – both should be considered experimental at this point. Jeff:  To wrap up the treatment section, let’s talk exotic snakes.  You may recall from the intro that these have a higher morbidity and mortality compared to native species. Nachi:  You will have to rely on your local poison control center or toxicologist for advice and you may even need to turn to the zoo or aquarium for antivenom, if it exists at all.  Patients with bites from exotic snakes should be monitored, likely in the ICU, for up to 24 hours as toxicity from some venom may have a delayed onset of up to 20 hours. Jeff:  Scary stuff, hopefully the patient knows which type of exotic snake they own and you don’t have to sort through a million google images to try to get to the bottom of this.  Anyway, there are 3 special populations to discuss.  First are pregnant patients. Nachi:  The authors cite a 1.4% incidence of snake bites in pregnant patients.  They note that this is low, but from my perspective, this seems shockingly high – why would a pregnant person ever get anywhere near a snake, seems just ill advised… Jeff:  haha, true.   But regardless, treatment is the same with antivenom as needed for all the same indications.  With fetal demise rates as high as 30%, in addition to maternal monitoring, the fetus should also be monitored. Nachi:  That number may seem high, but keep in mind that that’s from studies in other countries with more venomous snakes, so it’s likely to be lower in the US.  But the point remains, that antivenom is generally recommended to be given if the mother has indications for treatment, as poor fetal outcome is tied directly to the severity of envenomation in the mother. Jeff: Continuing right along, the next special population to discuss are pediatric patients.  Because dosing is based on the amount of venom delivered and not on patient specific factors, dosing is the same for peds and adults. Nachi:  How rare – so few meds seem to be the same for peds and adults.  The last population to discuss are anticoagulated patients.  Patients on antiplatelet or anti-coagulants are at increased risk of bleeding after pit viper envenomations and therefore should have their coags checked every 2 days following the last dose of FabAV. Jeff:  I think we’ve at least mentioned most of this months controversies, but it’s probably worth quickly reviewing them since they mostly dispel common myths. Nachi:  Good idea.  Incision and suction of snake bites is nearly universally not recommended. Jeff:  In the absence of ischemia, fasciotomy for snake bites is not recommended, even with elevated compartment pressures.  Instead treat compartment syndrome with anti-venom and save the fasciotomy for true cases of ischemia refractory to antivenom. Nachi:  With a known or suspected coral snake envenomation, due to shortages of NACSA, wait until the patient develops symptoms instead of empirically treating all bite victims. Jeff:  Maintenance dosing of FabAV continues to be debated.  The manufacturer recommends 2 doses every 6 hours for 3 doses while some experts recommend only maintenance dosing as needed.  It’s therefore probably safest to punt this to whatever poison control center or toxicologist you speak with. Nachi:  I feel like we are plugging the poison center a lot, but it’s such a good free, and usually very nice consult to have on your team. Jeff: Nice consultant – what a win!  Moving on to the cutting edge.  There is a new Crotalidae antivenom called Crotalidae Immune F(ab’)2 or, more simply, Anavip.  It should be available in the next few months.  The dosing will be 10 vials up front over 60 minutes followed by an additional 10 vials if the symptoms having been controlled.  4 more vials may be given for symptom recurrence.  Patients must be observed for a minimum of 18 hours after initial control of symptoms. Nachi: This would be a really nice development as Anavip has a longer half life and therefore should reduce the rates of late coagulopathy and decrease the need for maintenance dosing, follow up, and repeating coags. Jeff:  And finally, like we mentioned before, injection of the trypsin has been tried as a bridge to antivenom, as has carbon monoxide, which may mediate degradation of fibrinogen dependent coagulation. Nachi:  Alright, so let’s talk about the disposition next. Victims of pit viper envenomations should be monitored for 8-12 hours from the time of the bite.  They will need baseline labs and repeat testing ever 4-6 hours.  IF there is no progression of the symptoms and repeat testing is normal, the patient can be discharged. Jeff: Victims of coral snake bites should be admitted and observed for 12-24 hours regardless of symptoms. Nachi: Victims of rattle snake envenomations who initially develop hematologic abnormalities and are treated with FabAV should have repeat testing done in 2-4 days and 5-7 days. Jeff:  Wounds should also be closely followed to avoid complications and long term disfigurement and disability.  PT/OT may be necessary as well. Nachi:  Perfect, let’s round this episodes out with a review of the key points and clinical pearls from this month’s issue. There are about 10,000 ED visits in the US for snake bites each year, and 1/3 of these involve venomous species. Pit vipers produce a predominantly hemotoxic venom. Both local and systemic effects can occur. Systemic effects include tachycardia, tachypnea, hypotension, nausea, vomiting, weakness, and diaphoresis. In general, venomous snakes have a triangular or spade-like head, elliptical pupils, and hollow retractable fangs. In contrast, non-venomous snakes have a rounded head, round pupils, lack fangs, and can have a double row of vertical scales on the tail. Venomous North American coral snakes often have adjacent red and yellow bands, whereas their nonvenomous counterparts usually have a characteristic black band between the red and yellow bands. For prehospital care in the US, the following strategies are not recommended: incision or excision, use of venom extraction devices, tourniquets, chill methods, and electroshock therapy -- and they can all actually worsen outcomes.  Prehospital providers should focus on rapid transport. Be cognizant of compartment syndrome, but measure compartments when possible, as some envenomations present similarly but have only subcutaneous hypertension. Neurologic effects can be delayed up to 12 hours after coral snake envenomations. Symptoms can include a descending paralysis. For diagnostic testing, consider a CBC, coags, fibrinogen level, electrolytes, cpk, creatine, glucose, and urine studies.  All patients with envenomation should be observed for at least 8 hours. Mark the site of envenomation circumferentially to monitor for changes. Management of patients with snake bites should be treated with supportive care, pain control, and specific antivenom when indicated. FabAV or CroFab is the antivenom of choice for pit viper envenomations. Although FabAV will reduce the duration and severity of symptoms and lab abnormalities, it will not reverse tissue necrosis and may not reverse neurologic effects. Be aware of the possibility for a hypersensitivity reaction or serum sickness to FabAV. Treat with steroids, antihistamine, IV fluids, and epinephrine as appropriate. Coral snake envenomations can be treated with NACSA, which halts or at least limits the progression of muscle paralysis and shortens the clinical course.  Side effects to NACSA include dermal reaction as the most common -- and anaphylaxis as the most severe. Patients with bites from exotic snakes should be monitored, likely in the ICU, for up to 24 hours as toxicity from some venom may have a delayed onset of up to 20 hours. You may have to turn to your local zoo for help with anti-venoms here. Management of pregnant patients is the same as nonpregnant patients with regards to snake envenomations. Dosing of antivenom is based on the amount of venom. Dosing is the same regardless of the age of the patient. All patients requiring antivenom or with suspected envenomation should be admitted.  Seek consultation with your regional poison center and local toxicologist Jeff: So that wraps up the September 2018 episode of Emplify. Nachi: As always - the address for this month’s credit is ebmedicine.net/E0918, so head over there right away to get your credit.  Remember that the  you heard throughout the episode corresponds to the answers to the CME questions. Jeff: And don’t forget to grab your free issue of Synthetic Drug Intoxication in Children at ebmedicine.net/drugs specifically for emplify listeners. Feel free to share the link with your colleagues or through social media too. Next month we are talking sepsis and the ever frequently changing guidelines so it’s not something you want to miss.  Talk to you soon   Most Important References 4. *Lavonas EJ, Ruha AM, Banner W, et al. Unified treatment algorithm for the management of crotaline snakebite in the United States: results of an evidence-informed consensus workshop. BMC Emerg Med. 2011;11:2-227X-11-2. (Consensus panel) 6. *Bush SP, Ruha AM, Seifert SA, et al. Comparison of F(ab’)2 versus Fab antivenom for pit viper envenomation: a prospec­tive, blinded, multicenter, randomized clinical trial. Clin Toxicol (Phila). 2015;53(1):37-45. (Randomized controlled trial; 121 patients) 7. *Gerardo CJ, Vissoci JR, Brown MW, et al. Coagulation parameters in copperhead compared to other Crotalinae envenomation: secondary analysis of the F(ab’)2 versus Fab antivenom trial. Clin Toxicol (Phila). 2017;55(2):109-114. (Ran­domized controlled trial; 121 patients) 8. *American College of Medical Toxicology, American Acad­emy of Clinical Toxicology, American Association of Poison Control Centers, European Association of Poison Control Centres and Clinical Toxicologists, International Society on Toxinology, Asia Pacific Association of Medical Toxicology. Pressure immobilization after North American Crotalinae snake envenomation. Clin Toxicol (Phila). 2011;49(10):881-882. (Position statement) 10. *Wood A, Schauben J, Thundiyil J, et al. Review of eastern coral snake (Micrurus fulvius fulvius) exposures managed by the Florida Poison Information Center Network: 1998-2010. Clin Toxicol (Phila). 2013;51(8):783-788. (Retrospective; 387 patients) 48. *Cumpston KL. Is there a role for fasciotomy in Crotalinae envenomations in North America? Clin Toxicol (Phila). 2011;49(5):351-365. (Review) 75. *Walker JP, Morrison RL. Current management of copper­head snakebite. J Am Coll Surg. 2011;212(4):470-474. (Retro­spective; 142 patients) 81. *Kitchens C, Eskin T. Fatality in a case of envenomation by Crotalus adamanteus initially successfully treated with polyvalent ovine antivenom followed by recurrence of defibrinogenation syndrome. J Med Toxicol. 2008;4(3):180-183. (Case report) 118. *Hwang CW, Flach FE. Recurrent coagulopathy after rattle­snake bite requiring continuous intravenous dosing of anti­venom. Case Rep Emerg Med. 2015;2015:719302. (Case report)

In light of recent international negotiations over nuclear disarmament and efforts to respond to the use of chemical and poisonous weapons, we sit down with Dr. Erickson to discuss the health and environmental impacts of conflict and emergencies. Dr. Timothy B. Erickson is an emergency medicine physician at the Brigham and Women’s Hospital in Boston where he serves as the Chief of Medical Toxicology in the Department of Emergency Medicine, and a faculty member at the Harvard Humanitarian Initiative. He is an expert in environmental toxicology and crisis in climate change, and has active humanitarian health projects in conflict regions of Ukraine and Syria, as well as ongoing health projects in Nepal and India. Dr. Erickson earned his M.D. degree from The Chicago Medical School in 1986, and is a Fellow of the American College of Emergency Physicians, the American College of Medical Toxicology, the American Academy of Clinical Toxicology, and the National Geographic Explorers Club.

Author: Jared Scott, M.D. Educational Pearls: Cardiac myocytes and vascular smooth muscle are dependent on an intracellular calcium influx for contraction. Pancreatic beta cells rely on calcium to release insulin. Calcium channel blockers will decrease cardiac contractility and heart rate, but will also cause vascular smooth muscle relaxation with a subsequent decrease in systemic vascular resistance. Resultant cardiac depression and hypotension. Pancreatic beta cells also use calcium to release insulin, so calcium channel blockade can cause hyperglycemia. Treatment for calcium channel toxicity include: fluid resuscitation, calcium gluconate, vasopressors, and high dose insulin. Dosing for insulin therapy is usually 1-5 Units/kg/hr. Make sure to add dextrose!   References: Boyer EW, Shannon M. (2001).Treatment of calcium-channel-blocker intoxication with insulin infusion. New England Journal of Medicine. 344:1721. Proano L, Chiang WK, Wang RY. (1995).Calcium channel blocker overdose. American Journal of Emergency Medicine. 13:444. St-Onge M, Dubé PA, Gosselin S, et al. (2014). Treatment for calcium channel blocker poisoning: a systematic review. Clinical Toxicology. 52:926.  

Did you ever wonder what it’s like to explore the Amazon LOOKING for venomous, poisonous and toxic risks? Or how about pondering what it takes to get in the prestigious National Geographic Explorers Club? Or how about summiting Mt. Aconcagua or making it to Everest Base Camp, or even to Antarctica? How about curiosities as to what makes the Harvard Humanitarian Initiative tick and the amazing projects it undertakes to make the work a better, healthier, and safer place?  Well then you will enjoy this laughter filled and inspirational episode with the remarkable Dr. Tim Erickson. Tim is a Core Faculty at the prestigious Harvard Humanitarian Initiative, with expertise in environmental toxicology and crisis in climate change. He also has active humanitarian health projects in conflict regions of Ukraine and Syria. He’s also an emergency medicine physician at the Brigham and Women’s Hospital in Boston where he serves as the Chief of Medical Toxicology in the Department of Emergency Medicine. Dr. Erickson is a Fellow of the American College of Emergency Physicians, American College of Medical Toxicology, American Academy of Clinical Toxicology, and the prestigious National Geographic Explorers Club. Previously, he served as the Director for the Center for Global Health and Professor of Emergency Medicine and Medical Toxicology at the University of Illinois at Chicago’s College of Medicine. Dr. Erickson has been a member of multiple editorial boards and has a prolific academic history including publishing over 120 original journal articles and book chapters as well as editing 4 major textbooks. He has presented over 100 national and international invited lectures related to emergency medicine, toxicology, humanitarian global health, and wilderness/expedition medicine. And he has extensive international experience in Africa (Rwanda, Sudan, and Kenya), Asia (India, Vietnam, and Nepal), South America (Brazil, Peru, and Argentina), Europe (Kosovo, Ukraine, France) and Antarctica. But he’s also lobbed a snake at my daughter (it’s OK, it was rubber). His office is filled with blowgun darts that may or may not still have qari on their tips, as well as skulls and a variety of spiders and snakes, which I believe are all dead, but with Tim, you never know. So be warned…. In this episode we travel around the world to humanitarian hot spots as well as Antarctic rescues in very cold spots. We discuss his Tox-Boy beginnings and his current work at Harvard, and a great deal in-between.  Tim is the poster-boy for living a life in full—adventure, family, healing others, and training future and current physicians and healthcare providers—while have an amazing time doing it all.

Dr. Malcolm Kendrick is a medical doctor, author, speaker, and sceptic living in Cheshire, England.  His evidence-based arguments refute the lipid hypothesis and other ideas related to chronic illness that has resulted in a pervasive culture of fear and misinformation.  His popular blog features an ongoing series of posts on the real causes of heart disease, pointing to endothelial damage as a causal factor and nitric oxide as vital for preserving health. Dr. Kendrick is with us to share not only what really causes cardiovascular disease, but the specific environmental and psychosocial factors that cause the most harm, and what we need to do to maintain good health. We also discuss unexpected side effects of common medications and supplements and the healing power of specific micronutrients.  If you enjoy this podcast, you can support Dr. Kendrick’s work by pre-ordering his latest book, A Statin Nation: Damaging Millions in a Brave New Post-Health World, available 7/12/18. Here’s the outline of this interview with Malcolm Kendrick: [00:01:05] Book: The Great Cholesterol Con: The Truth About What Really Causes Heart Disease and How to Avoid it, by Malcolm Kendrick. [00:01:07] Book: Doctoring Data: How to Sort Out Medical Advice from Medical Nonsense, by Malcolm Kendrick. [00:01:14] The International Network of Cholesterol Skeptics (THINCS). [00:01:46] Trail Runner Nation Podcast: Metabolic Flexibility with Christopher Kelly. [00:02:59] Highlights email series. [00:03:01] Podcast: The True Root Causes of Cardiovascular Disease, with Jeffry Gerber. [00:03:07] Blog series: What causes heart disease? [00:05:28] Study: Hayashi, Keiko, et al. "Laughter lowered the increase in postprandial blood glucose." Diabetes care 26.5 (2003): 1651-1652. [00:06:20] Stress hormones, sympathetic nervous system. [00:07:32] Graph: Lithuanian death rate; Study: Kristenson, Margareta, et al. "Increased psychosocial strain in Lithuanian versus Swedish men: the LiVicordia study." Psychosomatic Medicine 60.3 (1998): 277-282. [00:08:25] Paul Rosch, M.D, founder of the American Institute of Stress. [00:10:20] Endothelium, glycocalyx. [00:11:12] Nitric Oxide (NO). [00:11:37] Alfred Nobel, nitroglycerin (glyceryl trinitrate, or GTN), Viagra. [00:13:13] Study: Andersson, Daniel P., et al. "Association between treatment for erectile dysfunction and death or cardiovascular outcomes after myocardial infarction." Heart (2017): heartjnl-2016. [00:13:39] Sunlight as nitric oxide stimulant. [00:14:45] Vasculitis, Systemic lupus erythematosus (SLE), Rheumatoid arthritis, Sickle-cell disease. [00:17:05] Endothelial progenitor cells. [00:17:55] Carl von Rokitansky, Rudolf Virchow. [00:21:19] Endothelial damage required for arterial plaque. [00:21:52] Study: Law, M. R., and S. G. Thompson. "Low serum cholesterol and the risk of cancer: an analysis of the published prospective studies." Cancer causes & control 2.4 (1991): 253-261. [00:23:49] Study: Ravnskov, Uffe, et al. "Lack of an association or an inverse association between low-density-lipoprotein cholesterol and mortality in the elderly: a systematic review." BMJ open 6.6 (2016): e010401. [00:25:03] Statins increasing NO, studies: 1, 2, 3. [00:26:52] Study: Lanphear, Bruce P., et al. "Low-level lead exposure and mortality in US adults: a population-based cohort study." The Lancet Public Health (2018). [00:28:17] Corticosteroids. [00:30:25] Familial Hypercholesterolemia. [00:34:56] Study: Winnik, Stephan, et al. "Systemic VEGF inhibition accelerates experimental atherosclerosis and disrupts endothelial homeostasis–implications for cardiovascular safety." International journal of cardiology 168.3 (2013): 2453-2461. [00:36:29] QRISK survey for heart disease. [00:41:21] Inflammation as healing. [00:42:40] Study: Willis, G. C. "The reversibility of atherosclerosis." Canadian Medical Association Journal 77.2 (1957): 106. [00:44:36] Corticosteroids reduce inflammation, increase CVD risk, NSAIDs. [00:45:05] Study: Guilhem, Gaël, et al. "Effects of air-pulsed cryotherapy on neuromuscular recovery subsequent to exercise-induced muscle damage." The American journal of sports medicine 41.8 (2013): 1942-1951. [00:49:06] Lipoprotein A. [00:51:27] Vitamin C deficiency as possible cause of CVD. [00:53:01] Study: Lee, A. J., et al. "Plasma fibrinogen and coronary risk factors: the Scottish Heart Health Study." Journal of clinical epidemiology 43.9 (1990): 913-919. [00:55:27] Diabetes, triglycerides, sepsis, gingivitis as procoagulants. [00:58:39] Major endothelial offenders. [01:00:03] Study: Escolar, Esteban, et al. "The effect of an EDTA-based chelation regimen on patients with diabetes mellitus and prior myocardial infarction in the Trial to Assess Chelation Therapy (TACT)." Circulation: Cardiovascular Quality and Outcomes (2013): CIRCOUTCOMES-113. [01:01:03] Study: Douaud, Gwenaëlle, et al. "Preventing Alzheimer’s disease-related gray matter atrophy by B-vitamin treatment." Proceedings of the National Academy of Sciences 110.23 (2013): 9523-9528. [01:01:44] Study: Marik, Paul E., et al. "Hydrocortisone, vitamin C, and thiamine for the treatment of severe sepsis and septic shock: a retrospective before-after study." Chest 151.6 (2017): 1229-1238. [01:02:27] Allen Smith, dying of flu, recovered with Vitamin C. [01:03:13] sunlight, viagra, stress management, alcohol. [01:04:23] Blue zones, strong social relationships. [01:05:07] Lifestyle and environmental factors associated with lower life expectancy. [01:13:05] Statins. [01:15:49] Absolute risk vs. relative risk; side effect vs. adverse effect, adverse events. [01:21:07] Problems caused by statins. [01:21:29] CoQ10, ATP. [01:23:47] Placebo effect, nocebo effect. [01:24:40] Study: Gupta, Ajay, et al. "Adverse events associated with unblinded, but not with blinded, statin therapy in the Anglo-Scandinavian Cardiac Outcomes Trial—Lipid-Lowering Arm (ASCOT-LLA): a randomised double-blind placebo-controlled trial and its non-randomised non-blind extension phase." The Lancet 389.10088 (2017): 2473-2481. [01:25:45] Study: Cohen, Jerome D., et al. "Understanding Statin Use in America and Gaps in Patient Education (USAGE): an internet-based survey of 10,138 current and former statin users." Journal of clinical lipidology 6.3 (2012): 208-215. [01:26:32] PCSK9 inhibitors. [01:27:54] Study: Sabatine, Marc S., et al. "Evolocumab and clinical outcomes in patients with cardiovascular disease." New England Journal of Medicine 376.18 (2017): 1713-1722. [01:35:16] L-arginine, citrulline. [01:39:34] Study: Tunstall-Pedoe, Hugh. "Does dietary potassium lower blood pressure and protect against coronary heart disease and death? Findings from the Scottish Heart Health Study?." Seminars in nephrology. Vol. 19. No. 5. 1999. [01:40:40] Study: Graudal, Niels. "A radical sodium reduction policy is not supported by randomized controlled trials or observational studies: grading the evidence." American journal of hypertension 29.5 (2016): 543-548. [01:43:55] Groupthink, cognitive bias. [01:44:21] Michael Alderman, M.D. [01:44:48] Evolutionary Psychology. [01:45:58] Peer Review. [01:51:36] Study: Bronstein, Alvin C., et al. "2010 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 28th Annual Report." Clinical Toxicology 49.10 (2011): 910-941. [01:52:57] Book: A Statin Nation: Damaging Millions in a Brave New Post-Health World, by Malcolm Kendrick.   [01:57:37] drmalcolmkendrick.org.

We recorded this live from the Joint Special Operations Medical Training Center where Guest Lecturer COL Givens, shares the CBRNe knowledge she has learned working (among many other positions) as a Clinical Toxicologist around the world including as the SOCAFRICA Command Surgeon where she personally helped prepare members of 10th SFG(A) to deal with some of the most venomous snakes in the world. COL Melissa (Missy) Givens MD, MPH is a graduate of the United States Military Academy and USUHS alumni. She is board certified in Emergency Medicine with subspecialty training in Clinical Toxicology and Sports Medicine and certification as a Strength and Conditioning Specialist. She is the former program director for the Carl R. Darnall Emergency Medicine Residency and EM-PA Fellowship. She has held various academic and operational assignments and completed several combat tours and deployments with both conventional and Special Operations Forces. COL Givens is currently faculty in the Department of Military and Emergency Medicine at USUHS.

This episode is focused on venomous lizards. The first half is all about the desert specialist and ultra-efficient Gila Monster. With the latter portion covering possibly the most charismatic lizard still roaming the earth – the iconic Komodo Dragon. We explore how these lizards interact with their environments and discuss the existence of their venoms. At the end we have the usual Species of the Bi-week who also harbours a dangerous toxin. FULL REFERENCE LIST AVAILABLE AT: herphighlights.podbean.com   Main Paper References: French, Robert, Daniel Brooks, Anne-Michelle Ruha, Farshad Shirazi, Peter Chase, Keith Boesen, and Frank Walter. 2015. “Gila Monster (Heloderma Suspectum) Envenomation: Descriptive Analysis of Calls to United States Poison Centers with Focus on Arizona Cases.” Clinical Toxicology 53 (1): 60–70. Fry, Bryan G, Stephen Wroe, Wouter Teeuwisse, Matthias J P van Osch, Karen Moreno, Janette Ingle, Colin McHenry, et al. 2009. “A Central Role for Venom in Predation by Varanus Komodoensis (Komodo Dragon) and the Extinct Giant Varanus (Megalania) Priscus.” Proceedings of the National Academy of Sciences of the United States of America 106 (22): 8969–74. OPEN ACCESS Gienger, C. M., C. Richard Tracy, and Kenneth A. Nagy. 2014. “Life in the Lizard Slow Lane: Gila Monsters Have Low Rates of Energy Use and Water Flux.” Copeia 2: 279–87. Purwandana, Deni, Achmad Ariefiandy, M. Jeri Imansyah, Aganto Seno, Claudio Ciofi, Mike Letnic, and Tim S. Jessop. 2016. “Ecological Allometries and Niche Use Dynamics across Komodo Dragon Ontogeny.” Science of Nature 103 (27): 26–37. Species of the Bi-Week: Serrano-Rojas, Shirley J., Andrew Whitworth, Jaime Villacampa, Rudolf Von May, Roberto C. Gutiérrez, José M. Padial, and Juan C. Chaparro. 2017. “A New Species of Poison-Dart Frog (Anura: Dendrobatidae) from Manu Province, Amazon Region of Southeastern Peru, with Notes on Its Natural History, Bioacoustics, Phylogenetics, and Recommended Conservation Status.” Zootaxa 4221 (1): 71–94. Other Mentioned Papers/Studies: Auffenberg W. 1981. “Behavioral ecology of the Komodo monitor. University Presses of Florida, Gainesville.” as cited in Fry et al. 2006 and Purwandana et al. 2016 Ariefiandy, Achmad, Deni Purwandana, Sanggar Abdil Nasu, Maman Surahman, Claudio Ciofi, and Tim Jessop. 2015. “First Record of Komodo Dragon Nesting Activity and Hatchling Emergence from North Flores , Eastern Indonesia.” Biawak 9 (1): 33–35. OPEN ACCESS Ashurst, John, and Robert Cannon. 2013. “Gila Monster Envenomation: A Review for the Emergency Medicine Physician.” JMED Research 2013: 1–4. OPEN ACCESS Daly, J. W., and C. W. Myers. 1967. “Toxicity of Panamanian Poison Frogs (Dendrobates): Some Biological and Chemical Aspects.” Science 156 (3777): 970–73. Davis, J. R., and D. F. DeNardo. 2007. “The urinary bladder as a physiological reservoir that moderates dehydration in a large desert lizard, the Gila monster Heloderma suspectum.” Journal of Experimental Biology 210 (8): 1472-1480. OPEN ACCESS Flannery, Tim 2002. The future eaters: an ecological history of the Australasian lands and people. New York: Grove Press. ISBN 0-8021-3943-4. Fry, Bryan G., Nicolas Vidal, Janette A. Norman, Freek J. Vonk, Holger Scheib, S. F. Ryan Ramjan, Sanjaya Kuruppu, et al. 2006. “Early Evolution of the Venom System in Lizards and Snakes.” Nature 439 (7076): 584–88.  Hargreaves, A. D.,  M. T. Swain, D. W. Logan, and J. F. Mulley. 2014. “Testing the Toxicofera: comparative transcriptomics casts doubt on the single, early evolution of the reptile venom system.” Toxicon 92: 140-156. OPEN ACCESS Hawlitschek, Oliver, Mark D. Scherz, Nicolas Straube, and Frank Glaw. 2016. “Resurrection of the Comoran Fish Scale Gecko Geckolepis Humbloti Vaillant, 1887 Reveals a Disjunct Distribution Caused by Natural Overseas Dispersal.” Organisms Diversity and Evolution 16 (1): 289–98.  Köhler, Gunther, Hans-Helmut Diethert, Ronald A. Nussbaum, and Christopher J. Raxworthy. 2009. “A Revision of the Fish Scale Geckos, Genus Geckolepis Grandidier (Squamata, Gekkonidae) from Madagascar and the Comoros.” Herpetologica 65 (4): 419–35.  Laver, Rebecca J., Deni Purwandana, Achmad Ariefiandy, Jeri Imansyah, David Forsyth, Claudio Ciofi, and Tim S. Jessop. 2012. “Life-History and Spatial Determinants of Somatic Growth Dynamics in Komodo Dragon Populations.” PLoS ONE 7 (9): 1–10. OPEN ACCESS Sims, David W., Emily J. Southall, Nicolas E. Humphries, Graeme C. Hays, Corey J. A. Bradshaw, Jonathan W. Pitchford, Alex James, et al. 2008. “Scaling Laws of Marine Predator Search Behaviour.” Nature 451 (7182): 1098–1102.  Other Links/Mentions: BBC Planet Earth II - Islands Clip on Komodo Dragons (Varanus komodoensis) https://www.youtube.com/watch?v=3Q05CSZAa8U BBC Zoo Quest for a Dragon 6 http://www.bbc.co.uk/archive/attenborough/7005.shtml Music – http://www.purple-planet.com

Jane and Dan speak to Professor Geoff Isbister is a clinical toxicologist and Director of Clinical Toxicology at the University of Newcastle. We talk to Geoff about: The spectrum of clinical presentations of serotonin toxicity Significant drug interactions with SSRIs: tramadol or linezolid? Current trends in pharmaceutical overdose Whether antivenoms are useful (and a shout out to our overseas listeners)

In this podcast I review "Trimethoprim-Sulfamethoxazole versus Placebo for Uncomplicated Skin Abscess" Talan et al NEJM 2016;374:823-32 and see what the clinical advantage to adding TM-SMX to simple I&D. Then we take a quick turn to some Tox and look at "Extracorporeal membrane oxygenation in the treatment of poisoned patients" deLange et al in Clinical Toxicology 2013;51:385-393.

This week on IAQ Radio we will interview Mr. Pertti (Bert) Hakkinen, Ph.D & Stephanie Publicker from the National Library of Medicine, National Institute of Health (NIH). Our discussion will focus on one of the most important and underutilized resources for environmental health professionals the National Library of Medicine, Specialized Information Services. We will also be discussing emergency services with Dr. Hakkinen especially as they relate to the current response to super storm Sandy. Pertti (Bert) Hakkinen, Ph.D., is the Acting Head of the Office of Clinical Toxicology, and the Senior Toxicologist and Toxicology and Environmental Health Science Advisor in the Division of Specialized Information Services, National Library of Medicine (NLM), National Institutes of Health (NIH). Dr. Hakkinen is the former project leader for the Wireless Information System for Emergency Responders (WISER) and the current project leader for the Chemical Hazards Emergency Medical Management (CHEMM) tools, represents NLM on various committees, and provides leadership for NLM's participation in national and international efforts in toxicology-, exposure-, and risk assessment-related information. Dr. Hakkinen received the 2011 "Risk Communication Excellence Award" from the Alliance for Chemical Safety for his work on the CHEMM project, and received one of the annual "NIH Director's Awards" (August, 2011), with this award recognizing a role in efforts led by NIEHS related to the Deepwater Horizon Gulf Oil Spill. Dr. Hakkinen has been an invited expert or reviewer for several U.S. EPA-, Health Canada-, and European Commission-sponsored efforts to develop or revise human exposure assessment guidance and resource documents and software, and was selected as a member of the core panel of experts in 2005-2007 for the Voluntary Children's Chemical Evaluation Program (VCCEP, a part of the Chemical Right-to-Know Initiative of the U.S. EPA). He is a co-editor and co-author of the latest edition of the Encyclopedia of Toxicology, and of the last two editions of the Information Resources in Toxicology book. Stephanie Publicker has an Associate Degree in Nursing, a BA in Italian and a Masters in Library Science. Since receiving her MLS from the University of Pittsburgh in 1991, she has been involved in end user training, getting her start when users were thrilled to have a 2400 Baud modem. She currently works in the National Library of Medicine's Specialized Information Services Division where she is involved in end user training, database development, and web content management. Join us this week and LEARN MORE about current happenings at the National Institutes of Health and more!

This week on IAQ Radio we will interview Mr. Pertti (Bert) Hakkinen, Ph.D & Stephanie Publicker from the National Library of Medicine, National Institute of Health (NIH). Our discussion will focus on one of the most important and underutilized resources for environmental health professionals the National Library of Medicine, Specialized Information Services. We will also be discussing emergency services with Dr. Hakkinen especially as they relate to the current response to super storm Sandy. Pertti (Bert) Hakkinen, Ph.D., is the Acting Head of the Office of Clinical Toxicology, and the Senior Toxicologist and Toxicology and Environmental Health Science Advisor in the Division of Specialized Information Services, National Library of Medicine (NLM), National Institutes of Health (NIH). Dr. Hakkinen is the former project leader for the Wireless Information System for Emergency Responders (WISER) and the current project leader for the Chemical Hazards Emergency Medical Management (CHEMM) tools, represents NLM on various committees, and provides leadership for NLM's participation in national and international efforts in toxicology-, exposure-, and risk assessment-related information. Dr. Hakkinen received the 2011 "Risk Communication Excellence Award" from the Alliance for Chemical Safety for his work on the CHEMM project, and received one of the annual "NIH Director's Awards" (August, 2011), with this award recognizing a role in efforts led by NIEHS related to the Deepwater Horizon Gulf Oil Spill. Dr. Hakkinen has been an invited expert or reviewer for several U.S. EPA-, Health Canada-, and European Commission-sponsored efforts to develop or revise human exposure assessment guidance and resource documents and software, and was selected as a member of the core panel of experts in 2005-2007 for the Voluntary Children's Chemical Evaluation Program (VCCEP, a part of the Chemical Right-to-Know Initiative of the U.S. EPA). He is a co-editor and co-author of the latest edition of the Encyclopedia of Toxicology, and of the last two editions of the Information Resources in Toxicology book. Stephanie Publicker has an Associate Degree in Nursing, a BA in Italian and a Masters in Library Science. Since receiving her MLS from the University of Pittsburgh in 1991, she has been involved in end user training, getting her start when users were thrilled to have a 2400 Baud modem. She currently works in the National Library of Medicine's Specialized Information Services Division where she is involved in end user training, database development, and web content management. Join us this week and LEARN MORE about current happenings at the National Institutes of Health and more!

Dr Michael Eddleston is a Reader in Clinical Toxicology and a Scottish Senior Clinical Research Fellow at the University of Edinburgh. Over 300,000 people die each year from pesticide self-poisoning, or suicide, in rural Asia. For many, death is unintentional, but the very high toxicity of pesticides means that deaths are all too common. This talk will engage this major public health problem and discuss the benefits of different prevention strategies. This lecture is part of the Medical Detectives, a series of public lectures that show how keen detective work is still essential for 21st century doctors: http://www.ed.ac.uk/news/events/medical-detectives/ Recorded on 22 September 2011 in the Anatomy Lecture Theatre at the University of Edinburgh.