Journal of The Korean Society of Clinical Toxicology

Sung Phil Chung

25 Articles

Demographic characteristics of patients admitted to the emergency department for intoxication and a time series analysis during the COVID-19 period: Bongmin Son, Nayoon Kang, Eunah Han, Gina Yu, Junho Cho, Jaiwoog Ko, Taeyoung Kong, Sung Phil Chung, Minhong Choa; J Korean Soc Clin Toxicol. 2023;21(2):92-107. Published online December 29, 2023; DOI: https://doi.org/10.22537/jksct.2023.00011

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Abstract PDF: Purpose: This study investigated the characteristics and treatment outcomes of patients who visited the emergency department due to intoxication and analyzed the impact of the coronavirus disease 2019 (COVID-19) pandemic on their visits.
Methods
A retrospective study was conducted using data from the National Emergency Department Information System (NEDIS) on patients who visited the emergency department due to intoxication between January 2014 and December 2020. In total, 277,791 patients were included in the study, and their demographic and clinical data were analyzed. A model was created from 2014 to 2019 and applied to 2020 (i.e., during the COVID-19 pandemic) to conduct a time series analysis distinguishing between unexpected accidents and suicide/self-harm among patients who visited the emergency department.
Results
The most common reason for visiting the emergency department was unintentional accidents (48.5%), followed by self-harm/suicide attempts (43.8%). Unexpected accident patients and self-harm/suicide patients showed statistically significant differences in terms of sex, age group, hospitalization rate, and mortality rate. The time series analysis showed a decrease in patients with unexpected accidents during the COVID-19 pandemic, but no change in patients with suicide/self-harm.
Conclusion
Depending on the intentionality of the intoxication, significant differences were found in the age group, the substance of intoxication, and the mortality rate. Therefore, future analyses of patients with intoxication should be stratified according to intentionality. In addition, the time series analysis of intentional self-harm/suicide did not show a decrease in 2010 in the number of patients, whereas a decrease was found for unintentional accidents.

Status and trends of medical expenditures for poisoning patients: Eung Nam Kim, Soyoung Jeon, Hye Sun Lee, Sung Phil Chung; J Korean Soc Clin Toxicol. 2023;21(1):24-31. Published online June 30, 2023; DOI: https://doi.org/10.22537/jksct.2022.00017

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Abstract PDF: Purpose: The purpose of this study was to estimate the medical expenditures for poisoning patients in Korea using data from National Health Insurance and the Korea Health Panel Survey.
Methods
The operational definition of poisoning was the presence of Korean Standard Classification of Diseases codes from T36 to T65. The number of poisoning patients, the amount of legal copayments, and benefit and non-benefit costs were extracted from both databases. The frequency of emergency, inpatient, and outpatient treatment utilization by poisoning patients was determined, and medical expenses were calculated. Linear regression analyses were performed to investigate factors affecting the medical expenses of poisoning patients.
Results
The number of poisoning patients increased from 97,965 in 2011 to 147,984 persons in 2020. Medical expenses also increased by 74% from Korean won (KRW) 30.1 billion to KRW 52.3 billion, and benefit costs also increased by 79%. The average outpatient cost per person was KRW 67,660, and the inpatient cost was KRW 1,485,103. The average non-benefit medical expenses were KRW 80,298, accounting for about 16.2% of the total expenses. Multivariable analysis showed that the total expenditure was associated with economic status and disabilities.
Conclusion
The average medical expenditure per poisoning patient was KRW 534,302 in 2020, and poisoning-related costs gradually increased during the study period. Further research on the economic burden of poisoning should include indirect costs and reflect disease-adjusted life years.

Causative Substance and Time of Mortality Presented to Emergency Department Following Acute Poisoning: 2014-2018 National Emergency Department Information System (NEDIS): Hyeonjae Lee, Minhong Choa, Eunah Han, Dong Ryul Ko, Jaiwoog Ko, Taeyoung Kong, Junho Cho, Sung Phil Chung; J Korean Soc Clin Toxicol. 2021;19(2):65-71. Published online December 31, 2021; DOI: https://doi.org/10.22537/jksct.2021.19.2.65

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Purpose: The purpose of this study was to investigate the cause of acute fatal poisoning and the time of death by analyzing the National Emergency Department Information System (NEDIS) of South Korea. Methods: The NEDIS data from 2014 to 2018 excluding non-medical visits were used for this study. The patients with acute poisoning were extracted using diagnostic codes. The toxic substances were classified into pharmaceuticals, pesticides, gases, artificial poisonous substances, and natural toxic substances. Patients were classified according to the time of death, place of death, and region. In each case, the most causative substances of poisoning were identified. Results: There were 380,531 patients including poisoning-related diagnoses, of which 4,148 (1.1%) died, and the WHO age-standardized mortality rate was 4.8 per 100,000. Analysis of 2,702 death patients whose primary diagnosis was acute poisoning, the most common cause of poisoning death was pesticides (62%), followed by therapeutic drugs, gas, and artificial toxic substances. Herbicides were the most common pesticides at 64.5%. The proportion of mortality by time, hyperacute (<6 h) 27.9%, acute (6-24 h) 32.6%, subacute (1-7 d) 29.7%, and delayed period (>7 d) were 9.8%. Conclusion: This study suggests that the most common cause of poisoning death was pesticides, and 60% of deaths occurred within 24 hours. The 71% of mortality from pesticides occurred within 6-24 hours, but mortality from gas was mostly within 6 hours. According to the geographic region, the primary cause of poisoning death was varied to pesticides or pharmaceuticals.

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A Novel Method for Medical Predictive Models in Small Data Using Out-of-Distribution Data and Transfer Learning
Inyong Jeong, Yeongmin Kim, Nam-Jun Cho, Hyo-Wook Gil, Hwamin Lee
Mathematics.2024; 12(2): 237. CrossRef
The 2022 Annual Report on Toxicology Surveillance and Severe Poisoning Cases at Emergency Departments in Korea
Eun Sun Lee, Su Jin Kim, Gyu Chong Cho, Mi Jin Lee, Byung Hak So, Kyung Su Kim, Juhyun Song, Sung Woo Lee
Journal of The Korean Society of Clinical Toxicology.2023; 21(1): 1. CrossRef
Demographic characteristics of patients admitted to the emergency department for intoxication and a time series analysis during the COVID-19 period
Bongmin Son, Nayoon Kang, Eunah Han, Gina Yu, Junho Cho, Jaiwoog Ko, Taeyoung Kong, Sung Phil Chung, Minhong Choa
Journal of The Korean Society of Clinical Toxicology.2023; 21(2): 92. CrossRef
Machine Learning-Based Prediction Models of Acute Respiratory Failure in Patients with Acute Pesticide Poisoning
Yeongmin Kim, Minsu Chae, Namjun Cho, Hyowook Gil, Hwamin Lee
Mathematics.2022; 10(24): 4633. CrossRef

Systematic review for economic benefit of poison control center: Eunah Han, Hyuna Hwang, Gina Yu, Dong Ryul Ko, Taeyoung Kong, Je Sung You, Minhong Choa, Sung Phil Chung; J Korean Soc Clin Toxicol. 2021;19(1):1-7. Published online June 30, 2021; DOI: https://doi.org/10.22537/jksct.2021.19.1.1

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Purpose: The purpose of this study was to conduct a systematic review to investigate the socio-economic benefits of the poison control center (PCC) and to assess whether telephone counseling at the poison control center affects the frequency of emergency room visits, hospitalization, and length of stay of patients with acute poisoning. Methods: The authors conducted a medical literature search of the PubMed, EMBASE, and Cochrane Library databases. Two reviewers evaluated the abstracts for eligibility, extracted the data, and assessed the study quality using a standardized tool. Key results such as the cost-benefit ratio, hospital stay days, unnecessary emergency room visits or hospitalizations, and reduced hospital charges were extracted from the studies. When meta-analysis was possible, it was performed using RevMan software (RevMan version 5.4). Results: Among 299 non-duplicated studies, 19 were relevant to the study questions. The cost-benefit ratios of PCC showed a wide range from 0.76 to 36 (average 6.8) according to the level of the medical expense of each country and whether the study included intentional poisoning. PCC reduced unnecessary visits to healthcare facilities. PCC consultation shortened the length of hospital stay by 1.82 (95% CI, 1.07-2.57) days. Conclusion: The systematic review and meta-analysis support the hypothesis that the PCC operation is cost-beneficial. However, when implementing the PCC concept in Korea in the future, it is necessary to prepare an institutional framework to ensure a costeffective model.

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2022 Annual Report of the Seoul Poison Control Center
Yo Han Shin, Sijin Lee, Su Jin Kim, Young Hoon Yoon, Sung Woo Lee
Journal of The Korean Society of Clinical Toxicology.2023; 21(1): 39. CrossRef

Acute Nicotine Poisoning due to Electronic Cigarette Liquid: Systematic Review of Case Reports: Si Yong Yang, Min Hong Choa, Je Sung You, Hyun Soo Chung, Sung Phil Chung; J Korean Soc Clin Toxicol. 2020;18(2):51-56. Published online December 31, 2020; DOI: https://doi.org/10.22537/jksct.2020.18.2.51

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Purpose: Acute nicotine poisoning by liquid nicotine in electronic cigarettes is becoming an increasing problem worldwide. The current systematic review aimed to determine the harm of acute nicotine poisoning by reviewing published case reports. Methods: An online literature search with PubMed, Embase, Cochrane Library, and KoreaMed database was performed to identify relevant studies addressing acute nicotine poisoning with electronic cigarettes. Two investigators searched the case reports written in English or Korean. Results: Twenty-six cases were included in this study. The routes of intoxication included ingestion in 18 cases, intravenous injection in three cases, subcutaneous injection in two cases, and ocular exposure in two cases. Ten cases had a cardiac arrest, and seven of them died. Seven out of 12 cases with intentional poisoning had a cardiac arrest. Nine children under 18 years were reported, and three of them had a cardiac arrest. Sixteen cases without a cardiac arrest recovered well, except for one case with sudden sensorineural hearing loss. Conclusion: The authors reviewed the risks of electronic cigarette liquid in terms of acute poisoning through a systematic review. The nicotine solution of an e-cigarette can be life-threatening in cases of acute poisoning. Therefore, active emergency treatment with early recognition is necessary. In addition, various management methods and regulations for preventing acute nicotine poisoning, such as restriction of distribution and nicotine concentration, should be considered.

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Electronic Nicotine, Non-Nicotine Delivery Systems, and Liquid Use by Flavoring and Nicotine Concentrations
Yeun Soo Yang, Hyeon Jeong Lim, Unchong Kim, Kyoungin Na, Heejin Kimm
Journal of the Korean Society for Research on Nicotine and Tobacco.2023; 14(3): 101. CrossRef

Analysis of Poisoning Patients Using 2017-18 ED Based Injury in-depth Surveillance Data: Jiyoon Koh, Woochan Jeon, Hyunggoo Kang, Yang Weon Kim, Hyun Kim, Bum Jin Oh, Mi Jin Lee, Byeong Jo Chun, Sung Phil Chung, Kyung Hwan Kim; J Korean Soc Clin Toxicol. 2020;18(2):85-93. Published online December 31, 2020; DOI: https://doi.org/10.22537/jksct.2020.18.2.85

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Purpose: The annual statistics for poisoning are reported based on the data from poison control centers in many advanced countries. In 2016 a study was conducted to analyze the 2016 Korea Poisoning status. This study was conducted to make a better annual report for poisoning statistics in Korea from a 2017-2018 national representative database. Methods: This study was a retrospective analysis of poisoning patients based on the data from an emergency department (ED) based injury in-depth surveillance project by the Korea Centers for Disease Control and Prevention in 2017-2018. Bite or sting injuries were not included. Results: A total of 17714 patients presented to 23 EDs because of poisoning. Adults above 20 years old age accounted for 84.6% of the population, while the proportion of intentional poisoning was 60.8%. The poisoning substance presented in the ED were therapeutic drugs (51.2%), gas (20.3%), pesticides (16.4%), and artificial substances (11.4%). Overall, 35% of patients were admitted for further treatment. The mortality was 2.4% (422 cases), and the most common fatal substances in order were carbon monoxide, other herbicides, and paraquat. Conclusion: This study showed the 2017-2018 status of poisoning in Korea. The prognosis is different from the cause of poisoning and the initial mental state of the patient. Therefore, appropriate methods for preventing poisoning and therapeutic plans in specific situations are needed.

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응급실 기반 중독 심층 실태조사 1차년도 결과 보고
성우 이, 수진 김, 규종 조, 미진 이, 병학 소, 경수 김, 주현 송
Public Health Weekly Report.2024; 17(14): 535. CrossRef
Status and trends of medical expenditures for poisoning patients
Eung Nam Kim, Soyoung Jeon, Hye Sun Lee, Sung Phil Chung
Journal of The Korean Society of Clinical Toxicology.2023; 21(1): 24. CrossRef
The 2022 Annual Report on Toxicology Surveillance and Severe Poisoning Cases at Emergency Departments in Korea
Eun Sun Lee, Su Jin Kim, Gyu Chong Cho, Mi Jin Lee, Byung Hak So, Kyung Su Kim, Juhyun Song, Sung Woo Lee
Journal of The Korean Society of Clinical Toxicology.2023; 21(1): 1. CrossRef
Prioritising Risk Factors for Prescription Drug Overdose among Older Adults in South Korea: A Multi-Method Study
Eun-Hae Lee, Ju-Ok Park, Joon-Pil Cho, Choung-Ah Lee
International Journal of Environmental Research and Public Health.2021; 18(11): 5948. CrossRef

Systematic Review of Vitamin B12 Regimen for Patient with Subacute Combined Degeneration of the Spinal Cord Following Nitrous Oxide Abuse: Jin Seok Chung, Min Hong Choa, Sung Phil Chung, In Cheol Park; J Korean Soc Clin Toxicol. 2019;17(2):79-85. Published online December 31, 2019; DOI: https://doi.org/10.22537/jksct.2019.17.2.79

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Abstract PDF: Purpose: The purpose of this study is to evaluate the effectiveness of vitamin B12 treatment in subacute combined degeneration (SCD) caused by nitrous oxide (N2O) abuse. Methods: Relevant literature was accessed through PubMed, EMBASE, Scopus, and KoreaMed. All the literature that was relevant to human use of vitamin B12 treatment for SCD caused by N2O abuse was included. Case reports were excluded if the treatment regimens were not precisely described. The literature search was conducted by two investigators during September 2019 for the final publication period. The languages of the publications were restricted to English and Korean. Results: Twenty-three published articles that contained 24 cases were included. Sixteen cases among them were treated with intramuscular vitamin B12 of 1 mg/day and the rest received different doses or routes. Although most cases described significant clinical improvements, one case showed no beneficial effect due to the patient's noncooperation. Another case showed adverse events, including spinal myoclonus, following vitamin B12 therapy. Conclusion: Vitamin B12 has been broadly used for the treatment of SCD caused by N2O abuse. However, most of the relevant studies were case reports that reported various regimens of vitamin B12 administration. Further studies are needed to establish a standard regimen of vitamin B12 because the incidence of N2O abuse may increase in South Korea.

Scombroid Fish Poisoning and Histamine Food Poisoning: Sung Phil Chung; J Korean Soc Clin Toxicol. 2019;17(1):1-6. Published online June 30, 2019; DOI: https://doi.org/10.22537/jksct.2019.17.1.1

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Abstract PDF: Scombroid fish poisoning (SFP) is a form of histamine food poisoning caused by the ingestion of improperly stored fish. The term "scombroid" derives from the family name of the fish family first implicated, such as tuna and mackerel. On the other hand, non-scombroid fish species, such as sardine and herring, can also cause histamine poisoning. The histamine is converted from histidine by a bacterial enzyme in the causative fish. Because the symptoms of SFP can easily be confused with food allergies, it is believed to have been significantly under-reported. In 2016, an outbreak of SFP occurred among primary school students who had eaten yellowtail steak in Korea. The most common findings consisted of a rapid onset of flushing of the face and trunk, erythematous and urticarial rash, diarrhea, and headache occurring soon after consuming the spoiled fish. Usually, the course is self-limiting and antihistamines can be used successfully to relieve symptoms, but several life-threatening SFP cases have been reported. Clinical toxicologists should be familiar with SFP and have competency to make a differential diagnosis between fish allergy and histamine poisoning. SFP is a histamine-induced reaction caused by the ingestion of histamine-contaminated fish, whereas a fish allergy is an IgE-mediated reaction. This review discusses the epidemiology, pathophysiology, diagnosis, treatment, and preventive measures of SFP.

Usefulness of Predictors for Hepatotoxicity in Acetaminophen Poisoning Patient: Eun Young Kim, Sung Phil Chung, Dong Ryul Ko, Tae Young Kong, Je Sung You, Min Hong Choa, Min Joung Kim; J Korean Soc Clin Toxicol. 2018;16(2):149-156. Published online December 31, 2018; DOI: https://doi.org/10.22537/jksct.2018.16.2.149

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Abstract PDF: Purpose: The purpose of this study was to determine whether hepatotoxicity could be predicted early using biochemical markers in patients with acetaminophen (AAP) poisoning and to assess the usefulness of predictive factors for acute liver injury or hepatotoxicity. Methods: This study was a retrospective observational study involving a medical records review. The participants were patients who were admitted to the emergency department (ED) with AAP overdose at two hospitals over a 10-year period. Demographic data, age, time from ingestion to visit, initial AAP level, initial hepatic aminotransferases, and initial prothrombin time were recorded. Acute liver injury was defined as a peak serum ALT >50 U/L or double the admission value, and hepatotoxicity was defined as a peak ALT >1,000 U/L. Receiver operating characteristic curve analyses were performed to compare the prognostic performance among variables. Results: A total of 97 patients were admitted to the ED with AAP overdose, of whom 26 had acute liver injury and 6 had hepatotoxicity. Acute liver injury was associated with the time interval after taking the drug, and hepatotoxicity was associated with the initial PT and the ALT level. The scoring system proposed by the authors has a significant ability to predict both acute liver injury and hepatotoxicity. Conclusion: To predict the prognosis of AAP poisoning patients, the time interval after taking AAP was important, and initial prothrombin time and ALT level were useful tests. Also a scoring system combining variables may be useful.

Comparison of Silymarin, Penicillin, N-acetylcysteine in Patient with Amatoxin Poisoning: A Systematic Review: Min Woo Choi, Dong Ryul Ko, Taeyoung Kong, Min Hong Choa, Je Sung You, Sung Phil Chung; J Korean Soc Clin Toxicol. 2018;16(1):33-41. Published online June 30, 2018; DOI: https://doi.org/10.22537/jksct.2018.16.1.33

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Abstract PDF: Purpose: This study was conducted to evaluate the clinical efficacy of pharmacologic treatment of amatoxin poisoning patients. Methods: Literature was accessed through PubMed, EMBASE, Cochrane library, KoreaMed, KISS and KMBASE. Studies relevant to human use of pharmacologic therapy including silymarin, penicillin and N-acetylcysteine (NAC) for amanita poisoning were included. Case reports, letters, editorials and papers with insufficient information were excluded. Comparison of clinical outcomes (especially mortality and liver transplantation rate) in each study was analyzed. Results: The final analysis included 13 retrospective studies. None of these studies showed direct comparisons of individual agents. Among 12 studies comparing silymarin vs penicillin, eight showed clinical superiority of silymarin. Among eight studies comparing silymarin with NAC, six showed clinical superiority of silymarin. Among seven studies of NAC vs penicillin, five showed clinical superiority of NAC. Conclusion: This systematic review suggested that clinical superiority of various pharmacological agents used to treat amatoxin poisoning is debatable. Nevertheless, the available evidence suggests it is reasonable to consider combinations of multiple agents for patients with amanita poisoning. Further studies are required to establish a treatment regimen for amanita poisoning.

Epidemiologic Characteristics of Intentional Poisoning: Emergency Department Based Injury in-depth Surveillance During 2011-2015: Hak Soo Lee, Juhee Han, Ji Hoon Kim, Sunpyo Kim, Sun Hyu Kim, Ji Sook Lee, Gyu Chong Cho, Chul Han, Joon Min Park, Sung Phil Chung, Min Joung Kim; J Korean Soc Clin Toxicol. 2017;15(2):131-139. Published online December 31, 2017; DOI: https://doi.org/10.22537/jksct.2017.15.2.131

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Abstract PDF: Purpose: The purpose of this study was to investigate the epidemiologic characteristics of patients who visited emergency departments (EDs) after intentional poisoning in Korea. Methods: This study retrospectively analyzed the data of of 23 hospitals during a five-year period, between 2011 and 2015. We included patients who inflicted injury to themselves - attempt of suicide - by means of poisoning. Results: A total of 18,121 patients visited an ED after intentional poisoning. Among them, 58.3% were females; however, there were more males among those aged 60 years or older. The mortality rate for males was 8.6%, which was 3.1 times higher than that for females with 2.8%. The most common poison was pesticides (35.4%) in males and sedative-hypnotics (44.0%) in females. The most common causative agent of death was pesticide in both sexes (75.2% and 65.3%, respectively). Since the production of paraquat was discontinued in 2011, the number of deaths from pesticide poisoning has decreased. The mortality rate declined in both males and females, from 12.6% and 4.5% in 2011 to 7.1% and 2.1% in 2015, respectively. Conclusion: In this study, we analyzed the epidemiologic characteristics of intentional poisoning, especially the frequency of suicide attempts by gender and age group, the cause of suicide, and the causative agent. This can be used as basic data for establishing policies to reduce and prevent suicide attempts by poisoning.

Fomepizole for Ethylene Glycol or Methanol Poisoning in Children: Ha Na Min, Yoon Jung Hwang, Dong Ryul Ko, Young Seon Joo, Tae Young Kong, Min Hong Choa, In Cheol Park, Sung Phil Chung; J Korean Soc Clin Toxicol. 2017;15(2):79-85. Published online December 31, 2017; DOI: https://doi.org/10.22537/jksct.2017.15.2.79

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Abstract PDF: Purpose: The purpose of this study is to evaluate the effectiveness and adverse effect of fomepizole in the management of acute ethylene glycol or methanol poisoning in children. Methods: Databases such as PubMed, Embase, Cochrane library, and KoreaMed were searched using terms related to fomepizole, ethylene glycol, methanol and pediatric. All studies, regardless of study design, reporting effectiveness or safety endpoints in children were included. Reference citations from identified publications were reviewed. Only reports written in English or Korean languages were included. The reference search was performed by two authors. Results: Twenty-two relevant literatures were finally included. They were one narrative review, 4 retrospective case series, and 17 case reports (19 cases). Case reports were classified as 5 fomepizole only, 8 fomepizole with other therapies, and 6 no fomepizole. All patients from the literatures were fully recovered without long term sequelae. Adverse effects of fomepizole were reported including anaphylaxis, thrombophlebitis and nystagmus. Conclusion: There are insufficient literatures regarding fomepizole treatment in children with ethylene glycol or methanol poisoning. The benefits or harms are not clearly established based on the clinical evidences. More prospective comparative studies are required in the future.

Analysis of Poisoning Patients Using 2016 ED Based Injury in-depth Surveillance Data: Sung Phil Chung, Mi Jin Lee, Hyunggoo Kang, Bum Jin Oh, Hyun Kim, Yang Weon Kim, Byeong Jo Chun, Kyung Hwan Kim; J Korean Soc Clin Toxicol. 2017;15(2):86-93. Published online December 31, 2017; DOI: https://doi.org/10.22537/jksct.2017.15.2.86

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Abstract PDF: Purpose: Some advanced countries have reported annual statistics for poisoning based on data from poison control centers. This study was conducted to propose a baseline format and statistics of poisoning in Korea from a national representative database. Methods: This study was a retrospective analysis of poisoning patients based on data from an emergency department (ED) based injury in-depth surveillance project by the Korea Centers for Disease Control and Prevention in 2016. Bite or sting injuries were not included. Variables related to poisoning were summarized using a similar format as the National Poison Data System in the United States. Results: A total of 7,820 poisoning patients presented to 23 EDs. Adults ${geq}20$ years accounted for 84% of the population, while the proportion of intentional poisoning was 59.4%. The most common poisoning substances were therapeutic drugs (45%), gas (21%), pesticides (15%), and artificial toxic substances (13%). Overall, 34.5% of patients were admitted for further treatment. The mortality was 3.2% (248 cases), and the most common causative substances were carbon monoxide, glyphosate, and paraquat, in order. Conclusion: This study showed the recent status of poisoning in Korea. However, a comprehensive poisoning registry based on poison control centers may be required to provide more accurate national statistics in the future.

Implementing Best Practice in Critically Ill Organophosphate Poisoned Patient Through Simulation-Based Learning Program: Ji Hwan Lee, Sung Phil Chung, Hyun Soo Chung; J Korean Soc Clin Toxicol. 2017;15(1):31-39. Published online June 30, 2017; DOI: https://doi.org/10.22537/jksct.2017.15.1.31

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Abstract PDF: Purpose: Despite the clinical and socio-economic impact of acute poisoned patients, many of the treatments are not standardized in Korea. Moreover, no formal training that is specifically focused on clinical toxicology exists. Rather, training and education are conducted case by case in various institutions. This study was conducted to develop a standardized simulation-based clinical toxicology training curriculum for healthcare providers. This program will focus on specific assessment and treatment of critical toxicology patients, specifically those who have been poisoned with organophosphate. Methods: The study was performed using a pre- and post-design to determine the effects of implementation of this program. The study was conducted at eight different urban teaching hospitals in a simulated room in the clinical area. The study was targeted to 19 groups composed of emergency residents and nurses. Simulation-based learning was conducted for each group. Results: All 19 groups achieved the minimum passing score of 75%. Implementation of the program led to improved performance rates for overall management and cooperative moods competency (p<0.01). Inter-rater agreement between the two evaluators was excellent. In general, the participants thought the program was realistic and were able to recognize and improve the competencies needed to care for organophosphate poisoned patients. Conclusion: Simulation-based learning is an effective educational strategy that can be applied to improving and understanding proper care for rare but critical patients. This program was effective at improving team performance and cooperative moods when managing an organophosphate poisoned patient in the Emergency Department.

A Case Report of Acute Nicotine Poisoning from Subcutaneous Injection of Nicotine Solution for Electronic Cigarette: Jiun Choi, Dong Ryul Ko, Je Sung You, Sung Phil Chung; J Korean Soc Clin Toxicol. 2017;15(1):60-64. Published online June 30, 2017; DOI: https://doi.org/10.22537/jksct.2017.15.1.60

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Abstract PDF: Nicotine-poisoning related to the electronic cigarettes (e-cigarette) is increasing worldwide. Moreover, the American Association of Poison Control Centers has advised the public to use caution with e-cigarette devices and highly concentrated liquid nicotine after a surge in related poisonings. We report here the first case of nicotine poisoning from self-injected e-cigarette fluid in Korea. A 17-year-old male patient subcutaneously injected himself with 0.5 ml of nicotine solution for an electronic cigarette via the dorsum of his hand, after which he complained of nausea, vomiting, dizziness and dyspnea. His vital signs were within the normal range, but his mental status was drowsy. He was admitted for observation and the symptoms disappeared the following day. Sinus bradycardia with a rate of 45/min was observed on the third hospital day, but improved after 6 hours. He was discharged without complications.

Extracorporeal Life Support in Treatment of Poisoning Patient: Systematic Review: Yong Hee Lee, Dong Ryul Ko, Taeyoung Kong, Young Seon Joo, Je Sung You, Sung Phil Chung; J Korean Soc Clin Toxicol. 2016;14(1):1-8. Published online June 30, 2016

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Abstract PDF: Purpose: Extracorporeal life support (ECLS) is a term used to describe a number of modalities including extracorporeal membrane oxygenation (ECMO) to support cardiac and/or pulmonary systems. The purpose of this study is to review the available evidence regarding the effect of ECLS in patients with acute poisoning. Methods: Electronic literature searches with PubMed, Embase, Cochrane library, and KoreaMed were conducted for identification of relevant studies addressing ECLS in treatment of acute poisoning. The literature search was conducted by two investigators in March, 2016 with publication language restricted to English and Korean. The toxic substance, technique of ECLS, and final outcome of each case were analyzed. Results: The final analysis included 64 articles including 55 case reports. There were no articles classified according to a high level of evidence such as randomized trial and prospective cohort study. ECLS treatment was used in the management of patients poisoned with 36 unique substances. Venovenous ECMO was performed in 4 cases. Among the reported cases, 10 patients died despite treatment with ECLS. Conclusion: Evidence supporting ECLS for patients with acute poisoning is inadequate. However, many case reports suggest that early consideration of ECLS in poisoned patients with refractory cardiac arrest or hemodynamic compromise refractory to standard therapies may be beneficial.

Effect of High Dose Insulin/Euglycemia Therapy for Acute Calcium Channel Blocker Intoxication: A Systematic Review: Jinmo Yang, Dong Ryul Ko, Taeyoung Kong, Young Seon Joo, Je Sung You, Sung Phil Chung; J Korean Soc Clin Toxicol. 2015;13(2):103-110. Published online December 31, 2015

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Abstract PDF: Purpose: The purpose of this study is to evaluate the effectiveness and the adverse events of high dose insulin/euglycemia therapy in acute calcium channel blocker (CCB) poisoning. Methods: We developed a systematic search strategy and applied it to 4 electronic reference databases. We searched medical journals as well as the bibliographies of relevant articles. All forms of literature relevant to human use of high dose insulin for acute CCB poisoning were included. The literature search was conducted by two investigators in August, 2015 with publication language restricted to English and Korean. Case reports were divided between CCB overdose alone and multi-drug overdose including CCB. The effect and adverse event of high dose insulin and clinical outcome of each case were analyzed. Results: Among 55 searched studies, 20 studies were included. A prospective study, a retrospective study, a systematic review study, and 17 case reports were identified. Case reports consisted of 11 CCB alone and 12 multidrug overdose cases including CCB. Although most cases described significant clinical improvements, one of them showed no beneficial effect. Several adverse events including hypoglycemia and hypokalemia were reported. No significant sequalae from adverse events was reported. Conclusion: Although there were many case reports demonstrating successful use of high dose insulin for CCB poisoning, the effect cannot be estimated due to a possibility of publication bias. Therefore, high dose insulin/euglycemia therapy might be considered adjunctive therapy in cases of CCB intoxication refractory for standard therapy.

Effect of Intravenous Lipid Emulsion in the Patient with Acute Poisoning : A Systematic Review: Jinwoo Myung, Dong Ryul Ko, Taeyoung Kong, Young Seon Joo, Je Sung You, Sung Phil Chung; J Korean Soc Clin Toxicol. 2015;13(1):1-10. Published online June 30, 2015

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Abstract PDF: Purpose: The purpose of this study was to evaluate the usefulness of intravenous lipid emulsion as well as adverse events in acute poisoning patients. Methods: Literature was accessed through PubMed, EMBASE, Cochrane library, Web of science, and KoreaMed. All forms of literatures relevant to human use of intravenous lipid emulsion for acute poisoning were included. Cases reports or letters without description of clinical outcomes for each case were excluded. The literature search was conducted by two investigators in March, 2015, with publication language restricted to English and Korean. The effect, onset time, and adverse event of lipid emulsion and final outcome of each case were analyzed. Results: Eighty-one published articles were included, excluding articles whose title and abstract were not relevant to this study. No articles were classified as high level of evidence. Sixty-eight case reports were identified, consisting of 25 local anesthetics and 43 other drugs, such as tricyclic antidepressants and calcium channel blockers. Although most cases described significant clinical improvements, some of them showed no beneficial effect or worsening of clinical course. Several adverse events including hyperamylasemia and laboratory interference were reported. Conclusion: Although there were many case reports illustrating successful use of lipid for various drug poisonings, the effect cannot be estimated due to significant possibility of publication bias. Therefore, lipids might be considered in severe hemodynamic instability resulting from lipophilic drug poisoning, however further studies should follow to establish the use of lipid as the standard of care.

The Clinical Characteristics for Emergency Endotracheal Intubation in Acute Drug Intoxication: Eol Han, Hyun Soo Chung, Yoo Seok Park, Je Sung You, Youngseon Joo, Taeyoung Kong, Incheol Park, Sung phil Chung; J Korean Soc Clin Toxicol. 2015;13(1):11-18. Published online June 30, 2015

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Abstract PDF: Purpose: The aim of this study was to compare the clinical characteristics in emergency endotracheal intubation between patients with acute drug intoxication and medical disease. Methods: Data for airway registry collected in two emergency departments (ED) between April 2006 and March 2010 were reviewed retrospectively. The airway registry data included patient's demographic information and variables such as Cormack-Lehane grade, 3-3-2 finger analysis, success rate, the number of attempts at intubation, complications of intubation, and clinical outcomes after intubation. Results: A total of 1480 patients were enrolled; 62 patients were classified as belonging to the intubation group after the drug intoxication group. No significant differences in Cormack-Lehane grade, 3-3-2 finger analysis, success rate, the number of attempts at intubation, and complications after intubation were observed between patients with acute drug intoxication and medical disease. However, significant difference was observed for indication of emergency endotracheal intubation. While emergency endotracheal intubations were usually performed in medical patients because of failure of airway patency, they were performed in intoxicated patients with the goal of preventing serious complications. Conclusion: Anatomical structures related to endotracheal intubation, the process and clinical outcome of intoxicated patients are not significantly different from those for medical patients.

L-carnitine vs Extracorporeal Elimination for Acute Valproic acid Intoxication: A Systematic Review: Byung Keun Yang, Jae Eun Ku, Young Seon Joo, Je Sung You, Sung Phil Chung, Hahn Shick Lee; J Korean Soc Clin Toxicol. 2014;12(2):39-45. Published online December 31, 2014

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Abstract PDF: Purpose: The purpose of this study is to review the evidence comparing the efficacy and safety between L-carnitine and extracorporeal elimination therapy in the management of acute valproic acid L-carnitine vs Extracorporeal Elimination for Acute Valproic acid Intoxication Methods: PubMed, Embase, Cochrane library, Web of Science, KoreaMed, KMbase, and KISS were searched, using the terms carnitine and valproic acid. All studies, regardless of design, reporting efficacy or safety endpoints were included. Reference citations from identified publications were reviewed. Both English and Korean languages were included. Two authors extracted primary data elements including poisoning severity, presenting features, clinical management, and outcomes. Results: Thirty two articles including 33 cases were identified. Poisoning severity was classified as 3 mild, 11 moderate, and 19 severe cases. Nine cases were treated with L-carnitine while 24 cases received extracorporeal therapy without L-carnitine. All patients except one expired patient treated with hemodialysis recovered clinically and no adverse effects were noted. A case report comparing two patients who ingested the same amount of valproic acid showed increased ICU stay (3 vs 11 days) in case of delayed extracorporeal therapy. Conclusion: Published evidence comparing L-carnitine with extracorporeal therapy is limited. Based on the available evidence, it is reasonable to consider L-carnitine for patients with acute valproic acid overdose. In case of severe poisoning, extracorporeal therapy would also be considered in the early phase of treatment.

A Systematic Review of Injury or Poisoning Related to Mercury Thermometer: Yo Seop Lee, Young Seon Joo, Je Sung You, Sung Phil Chung, Hyun Soo Chung, Hahn Shick Lee; J Korean Soc Clin Toxicol. 2014;12(1):22-30. Published online June 30, 2014

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Abstract PDF: Purpose: The purpose of this systematic review was to evaluate the evidence regarding injury and poisoning associated with the clinical mercury thermometer. Methods: Electronic literature searches were conducted for identification of relevant studies and case reports of injury and poisoning associated with the clinical mercury thermometer. The search outcomes were limited to literature with English and Korean languages published from 1966. Studies related to occupational mercury exposure, or mercury exposure from sphygmomanometer, barometer, and fluorescent light were excluded. Results: A total of 60 reports, including 59 case reports, were finally included. Of those, nine cases pertained to an intact thermometer as a foreign body, 25 injuries were related to a thermometer, and 26 cases involved exposures to mercury from a broken thermometer. Case reports were classified according to severity into 16 mild, 41 moderate, and two severe cases. Two cases of mortality were reported, one was deliberate intravenous injection of mercury and the other was acute vapor inhalation of mercury from broken thermometers. Conclusion: Findings of this systematic review suggested that the mercury thermometer could cause various forms of poisoning and injury. In particular, inhalation of mercury vapor from a broken thermometer can lead to systemic toxicity requiring chelating therapy.

A Case of Acute Hepatic Failure due to Acetaminophen Overdose Treated with Molecular Adsorbents Recirculating System$^{(R)}$: Byung Keun Yang, Je Sung You, Young Seon Joo, Sung Phil Chung, Hahn Schick Lee; J Korean Soc Clin Toxicol. 2014;12(1):31-34. Published online June 30, 2014

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Abstract PDF: We report on a patient who developed acute hepatic failure despite intravenous N-acetyl cysteine therapy who was treated with the Molecular Adsorbents Recirculating System (MARS). She presented 20 hours after the ingestion of 13 g of acetaminophen. The MARS is based on albumin dialysis principle which can be applied for patients with acute poisoning from drugs that have high protein-binding capacity because of its ability to selectively remove from circulation protein-bound toxins. The clinical toxicologist should be consider this technology when treating patients with hepatic failure following acetaminophen poisoning.

Two Cases of Intoxication with Phentermine: Jae Eun Ku, Young Seon Joo, Je Sung You, Sung Phil Chung, Hahn Shick Lee; J Korean Soc Clin Toxicol. 2014;12(1):35-38. Published online June 30, 2014

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Abstract PDF: Phentermine has been widely used as an appetite suppressant since 2004 in Korea. The authors experienced two cases of acute phentermine overdose and report with the literature review. A 36-year-old man and a 24-year-old woman presented together to the emergency department with taking 13 tablets (390 mg) of phentermine 16 hours ago. They had tachycardia, hypertension and complained visual symptoms, nausea, insomnia and anxiety. These symptoms were resolved by conservative management.

Clinical Characteristics of Intentional Carbon Monoxide Poisoning: Min Ki Cho, Yang Weon Kim, Kyeong Ryong Lee, Kyung Woo Lee, Jang Young Lee, Gyu Chong Cho, Junho Cho, Hyun Jong Kim, Seong Hwan Kim, Sung Phil Chung, Hahn Shick Lee; J Korean Soc Clin Toxicol. 2012;10(2):73-79. Published online December 31, 2012

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Abstract PDF: Purpose: The purpose of this study was to identify the changes in the characteristics of patients with carbon monoxide (CO) poisoning, as well as the distinctive differences in intentionally exposed patients. Methods: The medical records of CO poisoning patients, who visited nine emergency departments between January 2010 and December 2011, were reviewed retrospectively. The clinical information including age, gender, hospitalization, type of discharge, cause and location of exposure, site of onset, concentration of initial blood carboxyhemoglobin (COHb), methods of treatment and presence of neurological complications was examined. The subjects were divided into an intentional and non-intentional group and the differences between them was compared. Results: A total 209 subjects were recruited. The median age was 38 years (29~49.5 years). They frequently complained of nausea and vomiting, and the most common exposures occurred in winter, normally in the home. The cause of exposure was usually fire, followed by incomplete combustion of fuels. The median initial blood COHb was 13.15%. The proportion of intentionally exposed patients was 21%. They were significantly younger, more frequently discharged against medical advice, and showed a higher initial blood COHb level (22.85%) than the non-intentional group. Conclusion: This study suggests that those with intentional CO poisoning are normally discharged against medical advice even when they have a higher initial COHb level. An adequate explanation of the delayed neurologic sequelae and short term follow-up observation is recommended for those patients with intentional exposure.

Oral vs. Intravenous Administration of N-acetylcysteine in the Acetaminophen Poisoning: Hyo Ju Chae, Nu Ga Rhee, Hyun Jong Kim, Je Sung You, Sung Phil Chung, Hahn Shick Lee; J Korean Soc Clin Toxicol. 2012;10(2):97-102. Published online December 31, 2012

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Abstract PDF: Purpose: Serious acetaminophen (AAP) poisoning causes hepatotoxicity. N-acetylcysteine (NAC) is the most effective therapy for AAP poisoning and can be administered orally and intravenously (IV). Several studies have compared the efficacy of these two routes of administration and the results have been controversial. The purpose of this study was to compare the efficacy of oral and IV NAC for the prevention of hepatic toxicity in Korean patients whose serum AAP levels were higher than normal. Methods: A retrospective before/after study was performed, in which the patients presented to the emergency department with an AAP overdose from February 1995 to March 2012. A 3-day oral NAC regimen was used in the beginning, and a 20-hr intravenous regimen was then used from 2007. This study assessed the complications of an AAP overdose, such as hepatotoxicity, hepatic failure and renal failure as well as the side effects of the treatment regimen. Results: A total of 41patients was enrolled in this study. The median ALT and AST were 63 (IU/L) and 57 (IU/L) for the oral NAC treated patients, and 14 (IU/L) and 20 (IU/L) for the IV NAC treated patients (p=0.004 and p=0.001, respectively). The incidence of complications was similar in the treatment groups (p=0.399). Among the patients, 7 patients developed hepatotoxicity and were treated successfully with oral or IV NAC. Conclusion: This study suggests that IV NAC and oral NAC can prevent and successfully treat hepatic toxicity in patients whose serum AAP levels are higher than normal.

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