Toxicology

NSW Poisons Information Centre data identified 1030 deliberate prazosin self-poisonings over 11 years, rising from 13 to 170 per year (2014–2024). Young women predominated, likely due to expanded off-label (but accepted) psychiatric use of prazosin. Better evidence on benefits of off-label use is needed to justify increasing risks.

Olivia B. E. Lal, Nicholas A. Buckley, Rose Cairns

A multisectoral approach and stronger multilevel government coordination are required to address the health impacts associated with proximity to mining and exposure to toxic chemicals

Javier Cortes‐Ramirez · Ruby N Michael · Leisa‐Maree Toms · Melissa Haswell

A 63-year-old man was brought to the emergency department after a fall with prolonged floor lie of two days, complicated by urinary retention and acute kidney injury, in the context of peripheral neuropathy

Luke Collins · Logesh Palanikumar · Stephen Bacchi

A 70-year-old woman presented to the emergency department with symptomatic hyperkalaemia after excessive ingestion of potassium bitartrate to relieve constipation

Daniel Yee Lee Ng · Laksmi Govindasamy · Andrew Hughes · Hwee Min Lee

Physicians should know which medications should be prescribed in limited quantities and only after safer alternatives have been tried

Angela L Chiew · Geoffrey K Isbister

More toxic medicines should be supplied in limited quantities and their dispensing to individuals monitored

Jessy Lim · Nicholas A Buckley · Kate Chitty · Andrea L Schaffer · Jennifer Schumann · Zein Ali · Rose Cairns

Early collapse, a high risk feature of Australian snake envenoming, requires prompt identification and cardiopulmonary resuscitation

Geoffrey K Isbister · Katherine Z Isoardi · Angela L Chiew · Shane Jenkins · Nicholas A Buckley

To reduce opioid-related harms, we must support evidence-informed and timely detection and monitoring of nitazenes and emerging drugs; and harm reduction and clinical interventions

Brendan Clifford · Amy Peacock · Krista J Siefried · John Gobeil · Jennifer L Smith · Nadine Ezard

Edible cannabis forms may be less harmful than smoking cannabis, but the acute poisoning risk they pose must be considered

Rose Cairns · Sara Allaf · Nicholas A Buckley

A 75-year-old man presented with three days of lethargy and diarrhoea

Noor Lammoza · Maria Hormiz · Cherie Chiang · Chris Stead · Mustafa Ayhan · Samuel C Hume

Monitoring adherence to pharmacotherapy and safe medicine storage and disposal could reduce the risk of suicide

Kate M Chitty · Nicholas A Buckley · Jessy Lim · Zein Ali · Jennifer L Schumann · Rose Cairns · Benjamin Daniels · Sallie A Pearson · David B Preen · Andrea L Schaffer

A 23-year-old previously well Australian woman with no known allergies developed an erythematous, non- pruritic and non- tender rash while in Bali

Natalie SY Lee · Susan C Chu

Off-label use in young children suggests that health care professionals and the public underappreciate their risks

Abrar Arbaeen · Nial J Wheate · Jared A Brown · Rose Cairns

Further up-scheduling would probably reduce casual use and consequently the number of overdoses

Rose Cairns · Firouzeh Noghrehchi · Nicholas A Buckley

Most patients have taken a mixture of agents; the combination of GHB with methamphetamine is particularly frequent

Sam Alfred · Peter Stockham · Emma Partridge · Alastair Ward · Hannah Green · Jake Mallon · Chris Kostakis · Andrew Camilleri · Daniel Haustead

To the Editor: Paradoxically, both vitamin B6 deficiency and excess are associated with peripheral neuropathy. Increasingly, patients are presenting with peripheral neuropathy associated with elevated vitamin B6 whole blood levels, as previously presented by our laboratory.1 With a societal push towards wellness, there has been a greater uptake of over‐the‐counter vitamins in recent years. Magnesium is taken by patients for muscle, nerve and digestive issues, as well as for stress, anxiety and overall wellness. For some of these listed indications, the evidence is dubious. Vitamin B6 (as pyridoxine hydrochloride) is common among magnesium supplements based on the theory that the cellular uptake of magnesium is enhanced.2 These supplements are readily available in pharmacies, supermarkets and online, and contain up to 60mg of vitamin B6 per tablet. When purchasing magnesium supplements, patients may be unaware that they are also getting vitamin B6 and the quantity included could be hazardous to health. A patient taking two magnesium tablets per day could be unintentionally consuming 120mg of vitamin B6, now considered a large dose. This is far greater than the recommended dietary intake of vitamin B6 for adults in Australia and New Zealand of 1.3–2.0mg/day with a maximum of 50mg/day.3 The pharmacokinetics of pyridoxine hydrochloride are complex. Despite being water soluble, it has a half‐life of up to 30 days. Repetitive small doses taken over a period of months can accumulate, resulting in high blood concentrations. Vitamin B6 is associated with peripheral neuropathy when whole blood levels exceed 250nmol/L.4 Our laboratory recently presented a study showing that about 39% of our patients had elevated vitamin B6 whole blood levels (>190mol/L, the upper limit of our reference interval). The study included data from 88655 samples.1 A recent regulatory change from the Therapeutic Goods Administration mandated that products containing vitamin B6 in daily doses above 10mg now require a label warning.5 This previously applied to products containing over 50mg per daily dose. The Therapeutic Goods Administration has also reduced the maximum permitted daily dose from 200mg to 100mg for adults. It also noted cases where peripheral neuropathy developed in patients taking less than 50mg daily.5 This change applies to products produced after 1 March 2023 and therefore does not apply to products purchased before this date. In addition to being present in magnesium supplements, vitamin B6 (as pyridoxine hydrochloride) is contained in many multivitamins and energy drinks. Community awareness is key.

Gemma M Daley · David Kanowski · Lee Price

A 19-year-old man presented with a two-day history of intermittent pleuritic chest pain and associated fevers

Nilanthy Vigneswaran · Elaine Cheong

An 83-year-old woman of European ancestry had an initial diagnostic consideration of arsenical keratosis

Lachlan DW Lau · Anneliese Willems · Laura Scardamaglia

A 14-month-old girl was noted to have exfoliation of her peripheries on day 19 after orthotopic liver transplant for end-stage liver disease from extrahepatic biliary atresia

Jessica A Eldredge · Noel E Cranswick · Kathleen H McGrath

Despite its potential value, a number of questions require answers before its role in clinical practice becomes clear

Mark Little

Quantitative D-dimer assessment 2‒6 hours after snakebite could aid early diagnosis of envenoming with venom-induced consumption coagulopathy

Geoffrey K Isbister · Tina Noutsos · Shane Jenkins · Katherine Z Isoardi · Jessamine Soderstrom · Nicholas A Buckley

A 25-year-old woman presented via ambulance following a jellyfish sting

Anthony C Rengel · Sue Davel · Sarah O’Connor · Nicholas Medcraft