Abstracts of 2022 Middle East and North Africa Toxicology Association (MENATOX) Conference (11–14 May 2022, Muscat, Oman)

Injuries by marine creatures are a common presentation to Oman’s emergency departments (EDs). However, despite the difference in the marine fauna globally, there is no study on marine envenomation in Oman. We conducted a retrospective chart review of marine envenomation cases that presented to the ED at Khoula hospital, one of the main tertiary hospitals in Oman, between 2018 and 2019. We included patients of all ages who presented with injury secondary to contact with a marine creature. Multiple parameters were recorded, including causative creatures, symptoms, and medications. A total of 78 cases were included in this study, the majority (67.9%) were adults (18–64 years), and 82.1% were males. sea urchins accounted for most envenomations (52.6%). the pain was the most common presenting symptom (65.4%). the most common medication received in the ED was tetanus toxoid with non-steroidal anti-inflammatory drugs being the most prescribed medication on discharge. blood tests were obtained in seven patients. Imaging was done in 19 patients and X-ray was the most commonly ordered modality. All patients were discharged home on their first visit. six of the patients re-attended the ED for different reasons. Male adults were the most affected victims by marine envenomations in Oman. sea urchins accounted for most envenomations. None of the patients developed life-threatening symptoms.


Expert consensus on a lead exposure survey tool for the Middle East and North Africa region
Waleed Alsukaiti a , Hassan Albalushi b , Musa Alfaifi c and Ziad Kazzi d a ibri Hospital, ibri, oman; b school ofmedicine, Emory university, atlanta, ga, usa; c aseer Hospital, aseer, saudi arabia; d Emory university school of medicine, atlanta, ga, usa ABSTRACT We are developing a survey tool for the Middle East and North Africa region looking for possible lead exposure sources, we are collecting expert opinions in developing a MENA-specific lead exposure questionnaire from regional toxicologists in the Middle East and North Africa. We will make this questionnaire available to researchers, medical toxicologists, and public health professionals in the MENA region. the research team identified 100 case reports using PubMed. case reports of lead exposure in the MENA region were reviewed and the listed sources of exposure were extracted. Eighty four sources of lead exposure were identified. the list of exposures was sent to 10 medical toxicologists practicing in the MENA region to review. the scoring was based on the participant's experience in the MENA region. Kohl powder was identified as one of the sources of exposure with the highest importance (44%) while the consumption of peas and tomatoes, received the lowest score (15%) in terms of its importance as a source of lead exposure. Our expert consensus survey questionnaire captured all possible lead exposure sources that underwent extensive review by an expert group of toxicologists. the resulted questionnaire will serve as a resource for researchers, medical toxicologists, and public health professionals in the Arab region to conduct further studies and implement exposure prevention strategies.

Scorpion sting resulting in severe chest pain and elevated cardiac enzymes improved with scorpion antivenom: a case report and literature review
Waleed Alsukaiti a , saif Alsudairi a , Malak Albalushi b and rao rizwan a a ibri Hospital, ibri, oman; b ministry of Health, muscat, oman ABSTRACT scorpion stings are considered a common in Oman and the Arabian Peninsula and account for nearly one-fifth of human and animal stings and 20% of global stings. We report a scorpion envenomation in a 61-year-old female who presented with severe left sided typical chest pain after a scorpion sting to both hands. Her physical exam was remarkable for redness and mild swelling over the sting's sites in her fingers. EcG showed tWIs in leads V2 and III. cardiac enzymes were elevated with troponin of 210.60 pg/ml. Pericardial effusion was not present on echocardiography. scorpion Antivenom was administered to the patient. the patient was admitted and NstEMI protocol management was initiated. Her cardiac enzymes decreased and the patient was discharged on Day 3 in stable condition. the deceased scorpion was identified to be the Hottentotta jayakari scorpion from the abundant buthidae family. this scorpion has been reported before in Oman to cause demyelinating polyneuropathy in one case. the occurrence of acute coronary syndrome after Hottentotta jayakari sting is not common and possibly underreported in Oman. Myocardial ischemia by coronary spasm is believed to be due to the release of vasoactive, inflammatory, and thrombogenic peptides and amine constituents (histamine, serotonin, bradykinin, leukotrienes, thromboxane), which act on the coronary vasculature and induce coronary artery vasospasm and facilitate platelet aggregation as well as thrombosis. We aim to increase awareness about the risks of local scorpion envenomation from the common buthidae family.

Expert consensus for a national essential antidote list: e-Delphi method
Dalal Al-taweel a , samuel Koshy a , sara Al-Ansari b , Asmaa Al-Haqan a and bedoor Qabazard a a Kuwait university, Kuwait, Kuwait; b ministry of Health, Kuwait, Kuwait ABSTRACT Antidote stocking represents a major challenge to hospitals all over the world. An essential antidote list can be used as an initial foundation for securing sufficient antidote availability at healthcare institutions. the aim of our study is to generate a nationally relevant essential antidote list for emergency care hospitals in Kuwait using the e-Delphi method by establishing consensus through a multidisciplinary expert group of healthcare providers. An electronic survey with 47 essential antidotes was developed. the e-Delphi method was used, with three rounds of voting, to determine expert consensus on an essential antidote list for hospitals in Kuwait. A purposive sample of healthcare professionals from governmental and private hospitals was selected for this study (n = 30). the consensus was gained if ≥75% of the expert panel agreed on the inclusion of the antidote, without any strong disagreements. round 1 of the e-Delphi resulted in 41 antidotes reaching consensus and seven new antidotes suggested by the expert panel. round 2 had two antidotes (out of seven newly suggested ones) reaching a. consensus. round 3 was a confirmatory round, where the expert group agreed on their previous round's opinions. this resulted in the development of an essential antidote list with 43 antidotes. the optimal approach for ensuring adequate availability of antidotes is continuous monitoring of local poisoning incidence and antidote requirements through collaborations between academic researchers and emergency care clinicians. the e-Delphi technique can be used to consolidate recommendations of experts in emergency medicine to provide a relevant list of essential antidotes.
The dead do talk: postmortem toxicology from a forensic pathologist's perspective Jacqueline M. Martin georgia Bureau of investigation, Decatur, ga, usa ABSTRACT A large portion of the forensic pathologist's daily caseload involves instances in which toxicology becomes an intrinsic part of the correct certification of death. Obtaining suitable case history and scene investigation information, followed by an adequate postmortem examination is necessary to achieve this goal. Meaningful toxicology results depend on appropriate matrix selection, specimen preservation, and interpretation of results. Georgia (GA) has a state-wide system of medical examiners and coroners. the Georgia bureau of Investigation-Medical Examiner Office (GbI-MEO) provides services to 154 of 159 counties. A death is reported to the GbI-MEO by the county coroner following the criteria outlined in the GA Death Investigation Act, and the MEO accepts or declines the case. the coroners, together with the local authorities, are responsible for the investigation of the death, including obtaining an adequate medical and social history, considering the circumstances surrounding the death, and arranging for transportation of the body to the GbI-MEO. Once the body is received, the forensic pathologist (FP) performs a postmortem exam, the extent of which will depend on the case. the type of matrix selected (blood, vitreous, gastric contents, etc.) will largely depend on the history and the circumstances surrounding the death, and the condition of the body. the collection site and the preservation of the specimen collected are of utmost importance. If certain drugs are suspected, special handling of specimens is required. Once the results are obtained from the toxicology section, the FP is charged with the interpretation and correlation with the death.

Methadone use/abuse during Covid-19 pandemic at Sultan Qaboos University Hospital Emergency Department, Oman
Amina Al rawahi and suad Al Abri sQuH, muscat, oman ABSTRACT Methadone is listed as a maintenance therapy for opioid use disorder and significantly decreases overdose-related deaths. Opioid-related death due to Methadone use and abuse alarmingly increased during the cOVID-19 pandemic. this study aimed to assess the prevalence of Methadone use and abuse during the covid-19 pandemic at sultan Qaboos university Hospital (sQuH), emergency department (ED). this study was a retrospective observational study that included all patients who presented to the sQuH ED with a positive urine drug screen for methadone, from March 2020 until March 2021 during the cOVID-19 pandemic. Out of the 176 cases who had a positive urine drug screen, 151 (86%) were positive for morphine and only 5 (2.8%) were positive for methadone. Out of the methadone cases, the majority (n = 4, 80%) were males. regarding the clinical presentation, altered mental status was present in 3/5 (60%) of methadone abuse cases, followed by nausea, generalized body weakness, and agitation. seizure was present in 2 (40%) cases. Morphine and benzodiazepines were present with methadone in 3 (60%) cases. the majority (60%) were treated, evaluated, and released from the ED, while 40% were admitted and their hospital stay was complicated with aspiration pneumonia and opioid withdrawal syndrome. the incidence of positive urine drug screens for methadone in patients presenting to sQuH ED was low in comparison to morphine. the most common presenting sign and symptom was altered mental status followed by nausea, generalized body weakness, and agitation.

Acute mercury-induced lung injury treated with penicillamine in a newborn, a case report
Al Zahraa Al Mahrezi a , safaa A. L. Habsi b , badria Alhatali c and raya Al Habsi a a Department of Pediatrics, ibra Hospital, north ash sharqiyah, oman; b ibra Hospital, north ash sharqiyah, oman; c DEoH, muscat, oman ABSTRACT Mercury is considered a highly toxic element with potentially severe adverse health effects, after acute or chronic exposure. children exposed to mercury carry a higher risk of toxicity due to many factors and exposure during preconception, gestation, and the postnatal period. Despite the public increased awareness of the consequences of mercury poisoning, exposure in children is still present due to wrong traditional practices and beliefs. We report a case of severe acute respiratory distress syndrome (ArDs) following a possible inhalation of elemental mercury treated with D-penicillamine. A 29-days-old boy was brought to the emergency department with a one-day history of excessive crying, poor feeding, grunting, and lethargy. His clinical condition deteriorated fast, requiring intubation and ventilation followed by an Icu admission. His family gave a history of applying a locally prepared herbal paste all over the body and scalp, which was suspected to contain mercury. His whole blood and spot urine mercury levels were 122 µ/L (reference range <15 µ/L) and 123 µ/L (reference range <10 µ/L), respectively. chelation therapy with penicillamine was an essential part of the treatment due to the lack of other chelation agents with significant recovery. Exposure to elemental mercury vapor can cause severe acute respiratory distress and death among children. However, traditional treatments with items containing mercury are still widely used. therefore, Public education and increased awareness about the health impact of such practices are an important step in mercury poisoning prevention.
Case report of tetrodotoxin poisoning from Lagocephalus sceleratus in Lebanon suad A. L. sulaimani a,b , Nicholas titelbaum a , tharwat AlZahran c , ricardo El Ward c , sana chalhoub c and Ziad Kazzi a,d a Department of Emergency medicine, Division of medical Toxicology, Emory university school of medicine, atlanta, ga, usa; b Department of Emergency medicine, armed Forces Hospital, muscat, oman; c american university of Beirut medical center, Beirut, lebanon; d georgia Poison center, atlanta, ga, usa ABSTRACT the Indo-Pacific pufferfish Lagocephalus sceleratus is a tetrodotoxin-containing species believed to have entered the Mediterranean sea through the suez canal. this phenomenon is well-documented and has been termed the Lessepsian migration. tetrodotoxin (ttX) is primarily found in organs such as the liver, intestine, ovaries, and skin of L. sceleratus. Few cases of ttX attributed to L. sceleratus have been reported from the Mediterranean sea. We report Lebanon's first documented case of a patient with ttX poisoning from L. sceleratus consumption. A 46-year-old male presented to a hospital in Lebanon with perioral and extremity numbness associated with dizziness 1-hour post-ingestion of L. sceleratus fish (4.5 Kg). He caught and prepared the fish himself and ate a chunk of the meat part along its skin. Over the following 6 h, he developed dizziness, ataxia, and generalized body numbness. His hospital medical treatment included systemic hydrocortisone, antihistamine, activated charcoal (10 h post-ingestion), and fluids. He was admitted to the intensive care unit for two days where he developed sinus bradycardia (heart rate 40 bpm) but maintained normal blood pressure and oxygen saturation. At day 5 of his hospital stay, his numbness gradually subsided but his dizziness persisted. He was discharged home with residual lightheadedness that improved over the next few days after discharge. this is the first reported case of tetrodotoxin poisoning due to L. sceleratus in Lebanon. Public awareness regarding the toxicity of this species after ingesting any of its parts is essential to prevent toxicity and death.

Alpha-lipoic acid toxicity: the first reported mortality in an adult patient after multiorgan failure
Zeina Halabi a , christelle El Helou a , Hassan Al balushi b , Melissa Gittinger b , Alaina r. steck b , Ali Abu-Alfa c and tharwat El Zahran a a Department of Emergency medicine, american university of Beirut medical center, Beirut, lebanon; b Department of Emergency medicine, Emory university, atlanta, ga, usa; c Department of internal medicine, Division of nephrology, american university of Beirut medical center, Beirut, lebanon ABSTRACT there are 8 cases of alpha-lipoic acid (ALA) toxicity reported in the literature. three reported adult patients survived after the ingestion of 6 g, 4.5 g, and 18 g of ALA. Doses ranging from 1.8 to 6 g have been reported in five pediatric patients but only a 14-year-old female died after the ingestion of an estimated 6 grams of ALA leading to multiorgan failure. 42-year-old female presented to the emergency department 4 h after an intentional overdose of 10 tablets of ALA 600 mg each (6 g, 92.3 mg/kg). she developed refractory seizures, metabolic acidosis, thrombocytopenia, rhabdomyolysis, depressed cardiac contractility, kidney injury, and supraventricular tachycardia. Her condition deteriorated and she developed multiorgan failure. the patient was started on dual pressors, antiepileptic medications, high-dose insulin/euglycemia protocol, and methylene blue (1 mg/kg). Despite aggressive resuscitation, she required intubation and died. this is the 9th case and the first reported mortality from ALA toxicity with multiorgan failure in adults. Our patient shared some similar findings with previously reported cases, including refractory seizures, metabolic acidosis, thrombocytopenia, and rhabdomyolysis. refractory supraventricular tachycardia and severe agitation have not been reported with ALA toxicity before. the range of toxicity of ALA is not well established. A reported dose of 6 grams caused death in a pediatric patient as well as our patient but others survived a dose of 6 and 18 grams. toxicologists and emergency physicians should be prepared for clinical deterioration and consider aggressive resuscitation in severe ALA toxicity.

David Williams
World Health organization, geneva, switzerland ABSTRACT In 2017 WHO added snakebite envenoming to its neglected tropical diseases list. In 2018 the 71st World Health Assembly adopted a resolution calling on countries and WHO to undertake specific actions to tackle the problem. WHO launched a global strategic plan in 2019, during the 72nd World Health Assembly. these important steps, supported and sponsored by many countries around the world, have raised the profile of snakebites. this has attracted interest from donors, Ministries of Health, and civil society. WHO's strategy launch came in parallel with a us$100 million funding commitment from Welcome trust. several countries have added snakebite to national health plans. At WHO work to establish target product profiles (tPPs) for antivenoms and design a pilot antivenom stockpile facility for initial deployment in sub-saharan Africa is progressing. WHO has launched stage 1 of a snakebite Information and Data Platform to consolidate global data. to support improved data collection, a snakebite module for the District Health Information software 2 (DHIs2) system is being beta-tested in Africa. A WHO risk-benefit assessment procedure for antivenoms has been used to evaluate antivenoms used in sub-saharan Africa. Evaluations of antivenoms used in Afghanistan, bahrain, bangladesh, bhutan, Egypt, India, Iraq, Islamic republic of Iran, Israel, Jordan, Kuwait, Nepal, Pakistan, Occupied Palestinian territory, Oman, Qatar, saudi Arabia, sri Lanka, syrian Arab republic, united Arab Emirates, and yemen began in January 2022. Findings will be published by WHO. A community engagement and education toolkit, clinical training resources, and phone apps for health workers are being developed.

Saussurea costus: traditional uses and toxicity with experience from herbal shops in Oman
Hassan Al balushi a,b , suad Al Abri a,c , suad Al suliemani a,d , Waleed Al sukaiti a,e , Nadia Al Hajri a,f and badria Alhatali a,f a oman society of Emergency medicine, Toxicology club, muscat, oman; b Department of Emergency medicine, suhar Hospital, suhar, oman; c Department of Emergency medicine, sultan Qaboos university Hospital, muscat, oman; d Emergency medicineDepartment, armed Forced Hospital, muscat, oman; e Department of Emergency medicine, ibri Regional Hospital, ibri, oman; f Environmental and occupational Health, muscat, oman ABSTRACT Saussurea costus is a widely used medicinal plant in traditional medicine although there is no sufficient scientific evidence to support its benefits and safety. this is a literature review of the common medicinal uses and toxicity of S. costus supported by the experience of different herbal markets in the sultanate of Oman addressing the common indications for its use. Saussurea costus has been reported through experimental animal studies to have several medicinal benefits. costus extracts were described to have some anti-inflammatory, antitumor, anti-ulcer, and immunomodulatory effects. It has been also used in treating different thyroid disorders. Extracts of the roots have been used in the treatment of gastric cancer and human leukemia. In limited human studies, it was found to accelerate gastric emptying and increase endogenous motilin release. reported side effects include nausea, dizziness, and allergic reactions. We conducted visits to 10 herbal markets in the sultanate of Oman, and only 7 of them were found to sell costus. Indications were variable, where 42.8% used it to treat abdominal pain and 28.5% to treat intestinal worms. the dose prescribed ranged from a single tablespoon to an unspecified amount. One market gave instruction that it can be used in children and another one recommends it for breast mass treatment. S. costus is commonly available and used in herbal markets with different indications and doses. No specific regulations or standards are used in these markets. We recommend having clear regulations for the herbal medicinal use of S. costus.

Accidental retrobulbar injection of formalin: case report of successful management and resolution
ruba Omer a , tayseer Elhadi b and Muhammad Elamin c a alwalidin charity Eye Hospital, Khartoum, sudan; b Khartoum medicine information center, ministry of Health, Khartoum, sudan; c national Poisons information service (Birmingham unit), Birmingham, uK ABSTRACT Accidental eyelid injection of formalin is rare but can have serious consequences. Previous case reports document severe ophthalmic damage, lid contracture, exposure keratopathy, central retinal, ophthalmic artery occlusion, and ocular ischemic syndrome. We report a case of a successfully managed accidental retrobulbar formalin injection. A 19-year-old male presented to a tertiary eye hospital emergency department with football blunt trauma of the right eye, causing pain and deterioration of vision. Pupil examination demonstrated a fixed dilated pupil, ciliary injection, hazy cornea, and a shallow anterior chamber. there was a grade two hyphema with visual acuity detecting hand movement. Intraocular pressure (IOP) was elevated at 64.4 mmHg. He was commenced on dorzolamide eye drops, oral acetazolamide 250 mg, tobramycin, and dexamethasone eye drops every two hours. seven days later the patient developed corneal edema, elevated IOP 55 mmHg, and grade two hyphema. An anterior chamber wash under local anesthetic was planned. Following retrobulbar injection of what was believed to be 3 ml lidocaine, the patient immediately developed a progressively worsening local burning sensation at the site of the injection, after which the procedure was abandoned. After fifteen minutes, the patient complained of a severe headache, severe ocular pain, sweating, and cold extremities. An acute hypersensitivity reaction from lidocaine was initially suspected. Intravenous hydrocortisone, intramuscular diclofenac sodium, followed by oral diclofenac, and loratadine 10 mg tablets were administered with advice to continue other previously prescribed medications. On day two, the "lidocaine vial" was reviewed and found to contain a clear liquid with an offensive strong odor. Further investigation uncovered that the vial contained formalin 37%. the patient was recalled immediately and commenced on daily 50 mg prednisolone. On day three, the patient developed severe swelling of the right eyelid and conjunctival chemosis. He had corneal edema, and a fixed dilated pupil. cup to disc ratio (cDr) was 0.8, and visual acuity 1/60. the headache and ocular pain had resolved by day two. Following consultation with the Khartoum Medicines Information centre on day five, a ct scan for further assessment and topical anesthetic was recommended. by day seven, the swelling extended to the mandible. there was skin erosion below the right eye, grade 1 hyphema, and a fixed dilated pupil. Ocular motility was impaired, visual acuity 36/6, and the IOP elevated at 50 mmHg. the b-scan scan was clear. Prednisolone was tapered and co-amoxiclav commenced. the ct scan (day 8) demonstrated normal size and attenuation of the medial-lateral, rectus muscle, optic nerve, and free retrobulbar fat. by day twelve, visual acuity had improved (6/6), and IOP decreased (38 mmHg). Pilocarpine 2% eye drops bd were added. A week later, IOP had decreased to 14 mmHg with cDr of 0.4. the inferior rectus muscle was still impaired with erosion around the eye. three weeks later, the inferior rectus action was intact, the treatment was tapered, and stopped after two weeks. the erosion was healed but the patient complained of diplopia with fatigability. Accidental retrobulbar injection of formalin may have serious consequences; however, this patient did not develop severe ocular damage. IOP, cDr, and visual acuity improved within three weeks. the patient complained of diplopia with fatigability and remains under active follow-up at the time of this report. systems of clear labeling, storage, and handling of medicines are essential to help prevent similar incidents in future.

A case of metronidazole overdose causing ventricular fibrillation
Mohamed Elgassim, Amin saied, Moayad Elgassim, Amro Abdelrahman, Ibtesam AlJaufi and Waleed salem Hamad general Hospital, Doha, Qatar ABSTRACT Ventricular fibrillation is not a well-known complication of metronidazole poisoning. Arrhythmias have been reported as a complication of metronidazole intake while taking antiarrhythmic medications. Most arrhythmias are possibly related to the co-ingestion of other drugs with metronidazole as it interferes with the metabolism of these drugs. In this case, ventricular fibrillation occurred in a young patient without preexisting medical conditions or any other known drug ingestion. We report a case of an 18-year-old male who was brought in by ambulance after an intentional metronidazole overdose. On route to hospital, he developed ventricular fibrillation that was reversed by an electric shock. Laboratory investigations did not show any clear cause that might have precipitated his arrhythmia.

Assessment of clinical toxicological resources in countries belonging to the World Health Organization's Regional Office of the Eastern Mediterranean
Kieran Kristensen a , badria Alhatali b , tharwat El Zahran c and Ziad Kazzi a a Emory university school of medicine, atlanta, ga, usa; b Department of Environmental and occupational Health, ministry of Health, muscat, oman; c american university of Beirut, Beirut, lebanon ABSTRACT Poison centers (Pcs) are vital to healthcare capacity to prevent and manage toxic exposures. Many countries lack sufficient and comprehensive Pc services. WHO Eastern Mediterranean regional Office (EMrO) countries vary in economic and sociopolitical circumstances but lack a clinical toxicology resources assessment. this study interviewed Pc stakeholders to identify resources and capabilities. secondly, it included a survey of the EMrO clinical toxicology workforce to assess its needs. the Pc study was based on the WHO's Guidelines for Establishing a Pc center. Out of the 22 countries, 16 had Pcs. the team reached 13/16 Pc directors. Of these 13, 9 had call centers while the others had toxicological care units and/ or information center that was not available to the public. using a scoring system, it was found that many centers lack resources, coordination, and execution of toxicological initiatives. the areas of need were the availability of information centers, capacities of such centers, clinical toxicology units, laboratory services, and data collection/reporting. Areas in which the region performed better were toxicovigilance, management of chemical incidents, availability of free services, and use of information databases. the majority of the workforce stated a need for more compensation and support from the government, and a smaller majority needed increased professional development and research. Most had formal toxicology training and were active in research and clinically. Overall, the study identified crucial areas of need for the region, especially with regard to the establishment and expansion of call centers. More developed countries can assist those with less resources.

Chemical poisoning preparedness in Lebanon
Ali Ajrouch, Hanana Al tfaili, Hussein Awada, Hashem Nassereddine, Hassan Dhaini and salim Adib american university of Beirut, Beirut, lebanon ABSTRACT Lebanon suffers from a disproportionately high number of accidental poisonings, limited access to poison centers and services/antidotes, and minimal governmental intervention for the control and prevention of chemical poisoning incidents (cPI). Even before the recent collapse of the Lebanese health sector, standard solutions were challenging to realize. As literature is limited on this issue in Lebanon and other small regional low-income countries, we aimed to examine the current system and practices to make recommendations for better management of cPI in Lebanon and similar countries in the MENA region. through a qualitative approach, we identified and interviewed seven key stakeholders in chemical poisoning. the semi-structured interviews were transcribed and analyzed through thematic analysis to identify recurrent themes. Medication overdoses, detergents, and pesticides are the chief causes of cPI. case management does not follow any standardized protocols. the Ministry of Public Health provides minimal support to centers involved in cPI cases. there is a significant lack of trained personnel, financial support, and antidote inventories. Mandating cPI reporting, establishing a central national poison control call center, and raising public awareness about poisoning were the main recommendations for better management and preparedness. the Lebanese toxicovigilance system requires a significant overhaul. this necessitates establishing a national poison control center to provide the base on which a modern, efficient system can thrive. through recruiting and training qualified staff, establishing standardized cPI protocols, and coordinating awareness-raising programs and activities such a center would reduce cPI rates, save resources, and ultimately improve patient outcomes. Impact of pesticide restriction on suicide in Kerala-a 20-year study from 2001 to 2020 in a tertiary care centre M. sooraj a,b , Indira Madhavan a and Manu Johns a a government medical college, Thrissur, india; b cDsimER, Ramanagara, india ABSTRACT restricting access to toxic pesticides has been suggested as the most effective way to reduce the number of suicides in Asia. Apart from the National level ban in India, Kerala state has carried out a regional ban on certain harmful pesticides within the state mainly in the year 2011. We conducted a retrospective study of autopsies due to deliberate self-harm, at the Government medical college, thrissur to assess the suicide trend and the impact of the various pesticide regulations in Kerala on the suicide trend over the 20 years. there were total numbers of 14,593 suicide cases over 20 years from 2001 to 2020 with an average of 730 cases per year of which 4343 (29.8%) were poisoning cases and 10,250 (70.2%) were non-poisoning cases. Pesticides, plant poisons, drug over dosage, corrosives and unspecified poisoning were the common poison suicides recorded. total numbers of pesticide suicides were 2501 (57.6%), non-pesticide suicides were 577 (13.3%) and unspecified were 1265 (29.1%). Among non-poisoning suicides there were of hanging (n = 5137, 50.1%), burns (n = 2686, 26.2%), drowning (n = 2269, 22.1%) and others (n = 158, 1.6%). ratio between poisoning and non-poisoning suicides was reduced from 12/20 to 5/20 after 2011. there is a downward trend of overall suicide after 2011 and started increasing after 2017. Non-poisoning suicides follow similar trend as in overall suicide, but there's steady reduction of poison suicide reported after 2011 which could be attributable to restriction of harmful pesticides in 2011.
Prevalence and outcome of carbamazepine toxicity in patients presented to tertiary care hospital emergency department