In this special collaboration with NephMadness, we're diving into the world of nephrotoxins with an expert panel from Virginia Commonwealth University. NephMadness is an educational competition modeled after March Madness, and this year, one of the featured regions focuses on plant-based nephrotoxins. Together, with our expert panel we break down the competing nephrotoxin teams: Tubular Toxins vs. Oxalate Offenders.

Joining us are Dr. Anna Vinnokova (Nephrologist), Dr. Rachel Khan PharmD (Neph pharmacist), Dr. Ethan Downes (Nephrology fellow), and the legendary nephrotoxicologist, Dr. Josh King (Board certified Nephrologist and Toxicologist). We ALMOST named this episode "Getting Downe with the Mad Neph King and the Bean Queens"... but we didn't, your welcome.

After the show, go to the blog and vote for your favorite!

Expect irreverent musings, deep dives into toxic plant exposures, and a mystery case reveal that will leave you questioning your diet.

Topics and Timeline of Episode:

Intro

Listener Guesses With Josh and Ryan– 8:30

Listener Winner – 25:42

NephMadness and Guest Introductions – 28:07

Toxin Reveal – 33:41

• NEJM Case report

Tubular Toxins – 35:46

• Aristolochic Acid & the Belgian Weight-Loss Clinic Outbreak – 40:30
• Black Licorice & Its Surprising Toxic Effects – 47:16

The Oxalate Offenders Team: How Dietary Oxalates Harm the Kidneys – 52:00

• Historical Context: First recognized through sheep die-offs when herds grazed on Halogeton glomeratus, a high-oxalate plant, leading to fatal poisoning.
• Oxalate in Plants: Functions to bind excess calcium in the soil.
• Impact on the Body: Plants high in oxalate but low in calcium can contribute to oxalate accumulation, this leads to binding calcium in the blood, creating calcium oxalate crystals and acute renal calculi. Chronic inflammation from excess oxalate deposition leads to CKD progression.
• High-Oxalate Foods: Spinach, Swiss chard, rhubarb, cashews. Everything in moderation!

Practical Advice for Clinicians & Patients on Herbal Medicine Use – 1:00:00

• Resources for identifying nephrotoxic herbal products
• Talk to your patients non judgmentally, open conversations, discuss efficacy (or lack there of, see resources below) and safety
• Herbal medicines are not FDA approved and may not contain what they claim to

Herbals may not all be safe: Josh King Discovering Contaminants– 1:01:11

Wrap up– 1:08

Key Takeaways:

• Aristolochic acid is a direct nephrotoxin, associated with progressive kidney damage and urothelial cancers.
• Black licorice toxicity results from 11β-hydroxysteroid dehydrogenase inhibition, leading to excess cortisol activity, hypertension, potassium wasting, and rhabdomyolysis.
• Regulatory gaps in herbal supplements can lead to unexpected toxicities, making consumer awareness essential.
• High dietary oxalate intake increases the risk of kidney stone formation and chronic kidney disease.
• NephMadness is open to everyone—vote for your favorite nephrotoxin team and join the conversation!

Resources Mentioned:

• NephMadness: Follow along and fill out your bracket!
• AJKD Blog
• National Kidney Foundation Herbal Medicine Guide
• National Center for Complementary and Integrative Health (NCCIH)
• Poison Control Center (Available 24/7 for toxicology questions): 1-800-222-1222

Follow The Poison Lab:

• Twitter: @LabPoison
• Instagram: @tox_talk
• Website: www.ThePoisonLab.com

Don’t forget to rate and review the podcast on Apple Podcasts, Spotify, or your preferred platform. Share this episode with your fellow nephrology and toxicology enthusiasts!

Thanks for tuning in, and remember: If it sounds too good to be true, it might just be nephrotoxic. Stay safe and stay curious!

Do you think you know the cause of these symptoms? Send your guesses to [email protected] to take part in the next episode 

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Finally, the journal club to rule ALL journal clubs.

In this episode of The Poison Lab, we tackle one of the biggest topics in emergency medicine and toxicology: Should naloxone be given during opioid-associated cardiac arrest? With three fantastic studies published in 2024, we’re diving into the data and hearing directly from the authors themselves.

Join host Ryan Feldman as he interviews Dr. Eric Quinn, Dr. Joshua Lupton, and Dr. David Dillon, some of the minds behind the latest research exploring the role of naloxone in out-of-hospital cardiac arrest (OHCA). With perspectives ranging from clinical outcomes to practical implementation, this episode offers a deep dive into what these studies tell us—and what remains unanswered.

But that’s not all! Featuring special guests Spencer Oliver and Chris Pfingston from EMS 2020, this roundtable discussion incorporates the real-world insights of prehospital EMS professionals who face these decisions every day. Together, the panel unpacks:

• Conflicting evidence on naloxone’s impact on ROSC and survival.
• The challenges of interpreting retrospective studies in a high-stakes setting.
• Ethical dilemmas surrounding randomized trials for naloxone.
• Practical considerations for paramedics and emergency physicians in the field.

Whether you’re a toxicologist, EMS professional, or just curious about the intersection of drugs, overdose, and resuscitation, this episode is packed with actionable insights, expert opinions, and engaging discussions.

Tune in now to explore the science, controversy, and future directions for naloxone in cardiac arrest care!

Studies discussed in the show

• Outcomes of Out-of-Hospital Cardiac Arrest Patients Who Receive Naloxone in an EMS System with a High Prevalence of Opioid Overdose – Dr. Eric Quinn.
• Association of Early Naloxone Use with Outcomes in Nonshockable Out-of-Hospital Cardiac Arrest – Dr. Joshua Lupton.
• Naloxone and Patient Outcomes in Out-of-Hospital Cardiac Arrest in Northern California – Dr. David Dillon.

Studies and guidelines mentioned

• Editorial by Dr. Lavonas on Dr. Lupton's study
• AHA 2023 Guidelines for poisoning cardiac arrest
• AHA 2021 Position statement on opioid overdose out of hospital cardiac arrest
• Study of opioid overdose death after bystander naloxone training mentioned by Toxo

Shows mentioned

• Chris and Spencer's excellent EMS show
• Ryan's Interview on Poisoning Cardiac Arrest Guidelines with Dr. Eric Lavonas
• Journal club with Ryan and Dr. Dillon

• Podcast Introduction
• Overview of The Poison Lab and this episode’s focus.
• Introduction of the Topic
• Exploring naloxone use during out-of-hospital cardiac arrest (OHCA).
• Introduction of Guests
• Drs. Eric Quinn, Joshua Lupton, and David Dillon: authors of 2024 studies on naloxone in OHCA.
• Spencer Oliver and Chris Phingston: paramedics and co-hosts of EMS 2020.

Rationale for Studying Naloxone in OHCA

• Addressing the lack of evidence for naloxone use.
• High prevalence of opioid overdoses in study regions.
• EMS provider questions about naloxone’s role in suspected opioid-associated OHCA.

Overview of Existing Guidelines and Research

• 2021 AHA guidelines and scientific statement on opioid-associated OHCA.

Challenges in Determining Opioid Overdose as the Cause of OHCA

• Difficulties with pulse checks and drug testing limitations.

Summary of the Three 2024 Studies

• Dr. Quinn’s study: No significant benefit of naloxone.
• Dr. Lupton’s study: Benefit in early naloxone use for non-shockable rhythms vs no or late naloxone.
• Dr. Dillon’s study: Benefits of Naloxone in OOHCA, even in presumed non-drug-related OHCA cases.

Identifying Potential Opioid Overdose

• Importance of scene cues and patient history.

Study Methodologies and Confounding Factors

• Age as a significant confounder.
• Techniques used to control confounding (logistic regression, propensity score matching).

Potential Benefits and Harms of Naloxone in OHCA

• Risks of administering naloxone unnecessarily.
• Ethical concerns about withholding naloxone in trials.
• Broader physiological effects of naloxone.
• Challenges with current CPR ventilation techniques and naloxone’s potential role in improving respiratory drive.

Review of Current Guidelines

• AHA: Consider naloxone for high-risk cases.
• ILCOR: Does not recommend naloxone due to insufficient evidence.

Need for a Randomized Controlled Trial (RCT)

• Importance of defining naloxone’s role in OHCA.
• Challenges in RCT design, including ethical concerns and patient selection.

Final Takeaways

• Cautious optimism, but more research needed.
• Emphasis on standard ACLS protocols while awaiting further evidence.

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In this special holiday bonus episode, Ryan takes a look back at some of the most captivating episodes of The Poison Lab from 2022. Get ready for an ultimate test of your toxicology differential diagnosis skills as we compile all the "Stump the Toxicologist" segments into one streamlined, binge-worthy episode. Explore eight unique poisoning cases, be sure to check the show notes for a description of each case. time stamp of where it begins, and links to the original episodes, where you can dive deeper into the discussions and unravel the mysteries behind these intriguing cases!

Case Teasers and Time Stamps

Episode 13, March 2nd, 2022: Dr. Howard Greller

• 0:06:19 Case 1: A 19-year-old male collapses at home and presents to the ED unresponsive, tachycardic, and hypotensive, with a wide QRS complex on EKG and a serum lactate of 20.
• 0:22:58 Case 2: A 16-year-old female presents to the ED 9 hours after ingesting 100 tablets of an unknown medication in a suicide attempt. She presents with vomiting, lethargy, bloody diarrhea, and a metabolic acidosis. An abdominal x-ray shows numerous radiopaque tablets in her GI tract. She is treated with a redacted antidote and whole bowel irrigation, but her condition worsens and she develops liver failure. She is transferred to a tertiary care center for a liver transplant, but recovers. On day 12, she develops a lower GI bleed and bowel perforation and dies.
• 0:34:42 Case 3: A seven-month-old child presents with crying, cough, vomiting, and respiratory distress.
• 0:37:42 Case 4: A 32-year-old male with a history of alcohol use and depression presents to the ED seven hours after ingesting two handfuls of an unknown medication and alcohol in a suicide attempt. He is initially anxious and tremulous, but has normal vital signs and labs, aside from an elevated ethanol level. He has a seizure nine hours after ingestion. His EKG shows a widened QRS, and he becomes hypotensive. He is intubated, placed on vasopressors, and undergoes extracorporeal membrane oxygenation (ECMO) and targeted temperature management (TTM), but dies three days later.

Episode 15, July 6th, 2022: Dr. Josh Trebach

• 0:46:11 Case 1: Two British medical students present to the ED after developing nausea, vomiting, paresthesias, myalgias, pruritus, and cold allodynia 12 hours after sharing a meal. Their neurological symptoms persisted for 4 weeks and the cold allodynia for 10 weeks.
• 0:54:18 - 1:05:23 Case 2: A 16-year-old female presents to the ED unresponsive and cyanotic after intentionally ingesting a substance purchased online. Her oxygen saturation is in the 70s and a methemoglobin level is greater than 30%.
• 1:05:25 - 1:10:18 Case 3: A 48-year-old female, and co-author of the published case report, presents to the ED 10 minutes after eating a “peppery” tuna steak. She is tachycardic, hypotensive, flushed, and has conjunctival erythema. She also experiences abdominal pain, nausea, vomiting, diarrhea, headache, and chest pain. Her EKG shows tachycardia with ST depression. She requires phenylephrine to maintain her blood pressure. She is treated with famotidine and discharged from the hospital 43 hours later.
• 1:10:20 – 1:13:16 Case 4: A 63-year-old female presents to the ED 12 hours after ingesting five capsules of a weight loss product. She is bradycardic and has nausea, vomiting, and hyperkalemia.

Episode 17, November 9th, 2022: Dr. Emily Kieran

• 1:16:35 Case 1: A 34-year-old female presents to a clinic in West Bengal, India, with a three-year history of skin changes. She has hypo-pigmented macules on a background of hyperpigmentation, creating a “raindrop” like appearance on her chest, hands, and soles.
• 1:19:17 Case 2: An 85-year-old male with a history of Alzheimer’s dementia, COPD, and depression calls 911 for symptomatic hypoglycemia and goes into cardiac arrest after EMS mistakenly administers an unknown substance instead of dextrose 10% (D10). He is asystolic upon arrival to the ED, but achieves return of spontaneous circulation (ROSC) after receiving sodium bicarbonate and 100 mL of 20% intralipid. He subsequently develops wide-complex tachycardia, hypertension, and hypotension, and dies 12 hours later.
• 1:25:05 Case 3: A 22-month-old female with no past medical history is found altered by a caretaker and brought to the ED. She is tachycardic, with a normal blood pressure and oxygen saturation. She does not respond to naloxone and a CT scan shows severe anoxic brain injury and herniation. She is treated with vasopressors and anticonvulsants, but is declared brain dead several days later.
• 1:29:26 Case 4: A 45-year-old male with a history of hypertension presents to the ED with severe vomiting and diarrhea that began the morning after he ate two dozen oysters he had caught and cooked two days prior. He initially presents with tachycardia and borderline low blood pressure, but his labs are normal. He becomes increasingly confused over the next several hours and develops a tonic-clonic seizure. He has persistent neurological sequelae, including short-term memory loss, and is discharged from the hospital after 86 days.

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Join host Ryan Feldman in an insightful episode of "The Poison Lab" as he sits down with Dr. John Downs, Director of the Virginia Poison Center, and one of the leading experts on per- and polyfluoroalkyl substances (PFAS), commonly known as "forever chemicals." Known for their persistence in the environment and human body, PFAS have raised significant public health concerns over the past few decades. Dr. Downs shares his journey through occupational medicine, toxicology, and public health, which uniquely positioned him to provide expertise on PFAS exposure, health risks, and ongoing regulatory efforts. Together, they delve into the origins, uses, and potential health effects of these ubiquitous compounds, while examining government policies, environmental impact, and strategies to reduce exposure. A must-listen for anyone interested in the intersection of environmental health and toxicology!

Episode Breakdown:

• 2:42 – What Are Forever Chemicals?
• 8:01 – History of PFAS and Associated Health Concerns
• 15:41 – Government Regulation of PFAS
• 20:42 – Shortcomings in PFAS Regulation
• 25:20 – How Individuals Can Mitigate Risk
• 31:15 – Testing for PFAS Levels and Exploring Treatment Options
• 41:14 – Future Directions and Research Needs for PFAS
• 45:29 – Conclusion and Outro

Key Topics Discussed

2:42 – What Are Forever Chemicals?

• PFAS are a large group of man-made chemicals that are persistent in the environment and human body.
• The podcast focuses primarily on PFOA (perfluorooctanoic acid) and PFOS (perfluorooctanoic sulfonic acid), as these were the first compounds identified as having very long elimination half-lives, measured in years, and not undergoing significant human metabolism
• The podcast mentions that there are potentially thousands of different PFAS compounds and that more research is needed to determine if they all induce the same health effects as PFOA and PFOS
• Commonly used for their water- and oil-resistant properties in nonstick cookware, fast food wrappers, firefighting foams, and more.

8:01 – History of PFAS and Associated Health Concerns

• First created by Dupont chemical, used widely in 1940's in Teflon
• Large contamination of water by PFAS identified in West Virginia town
• Led to landmark study in West Virginia (the C8 study) on epidemiological data of PFAS-related health risks.
• Effects noted: High cholesterol, thyroid dysfunction, ulcerative colitis, hypertension in pregnancy, decreased immune response to vaccine, and certain cancers (testicular and kidney cancer).

PFAS in the Environment

• PFAS are not easily degraded, leading to bioaccumulation in humans and animals.
• Non-stick cookware: Teflon, the trade name for non-stick cookware, was one of the earliest applications of PFAS, utilizing PFOA.
• Firefighting foam: PFAS was used in firefighting foams, particularly for aviation fuel fires. This has led to contamination of groundwater around military installations and airports.
• Fast food wrappers and other consumer products: PFAS are used to make products water and oil resistant, including fast food wrappers, clothing, upholstery, and popcorn bags.
• Biosolids: The nitrogenous waste produced after wastewater treatment, have been found to contain concentrated PFAS. These biosolids are sometimes sold to farms as fertilizer, potentially contaminating water and crops.
• Ski wax: Ski waxers have been found to have a high degree of PFAS exposure10.
• Major sources contaminated drinking water, military bases, and consumer product (Teflon, waterproof jackets, popcorn bags etc...)

15:41 – Government Regulation of PFAS

• EPA Health Advisory Limits (2009): These were the first non-enforceable limits set for PFOA and PFOS in drinking water. These limits were revised several times over the next 15 years, becoming progressively lower.
• EPA Enforceable Limits (2024): The EPA published its final rule for enforceable limits, known as maximum contaminant levels (MCLs), in April 2024.
• The goal is for PFOA and PFOS to be completely non-detectable in drinking water
• Recognizing that non-detect is difficult to achieve, the EPA set an MCL of 4 parts per trillion for both PFOA and PFOS.
• A combined limit of 10 parts per trillion was set for four other unspecified PFAS compounds.

Practical Steps for Individuals

• Tips for reducing personal PFAS exposure, such as using alternative cookware, avoiding certain fast-food packaging, and considering home water filtration.

The Future of PFAS Management

• Ongoing need for more research to fully understand PFAS health impacts and develop effective mitigation strategies.
• He discusses potential alternatives to PFAS and the importance of balancing industrial needs with public health concerns.

Additional Resources

• Books: Exposure by Rob Bilott (inspiration for the film Dark Waters)
• CDC and EPA websites for information on PFAS and water quality testing
• Dr. Downs guidance from the American College of Medical Toxicology

Ryan on others shows

• Ryan on "22 at the Lips"
• Ryan on  "Continuing Studies"

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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.  

Link to published abstract manuscript

Abstracts

07:48-Abstract #1. The NACSTOP2 trial: a multi-center randomized controlled trial investigating the early cessation of n-acetylcysteine in acetaminophen overdose

• Guest- Dr. Anslem Wong, MD, PhD

21:33- Abstract  #36. ECG intervals: does one size really fit all?

• Guest- Dr. Caitlin Roake, MD, PhD

25:41- Abstract #85. Do abnormal electrocardiographic intervals predict death in poisoned patients older than 65 years?

• Guest- Dr. Michael Chary, MD

30:06- Abstract #61. Minimum tetrahydrocannabinol dose that produces severe symptoms in children <6 years old with cannabis edible ingestions

• Guest- Dr. Keahi Horowitz, MD

36:25- Abstract #114. Frequency and severity of cannabis toxicity before and after legislative change to increase cannabis edible package size

• Guest- Dr. Robert Hendrickson, MD

38:24- Abstract #101. Quantification of acetaminophen line-crossers in the setting o f overdose with delayed gastric absorption

• Guest- Dr. Jamie Sterr, PharmD

41:41- Abstract #175. Cause for pause: bradycardia induced by transdermal rivastigmine in anticholinergic delirium

• Guest- Dr. Santiago Batista Minaya, MD

46:21- Abstract #199. Cerebellar, hippocampal, and basal nuclei transient edema with restricted diffusion (CHANTER) Syndrome with poor neurological outcome in the setting of suspected opioid use

• Guest- Jack Yang and Dr. Avery Michienzi, DO

49:49- 191. Severity scores for caustic injury: Zargar they even used?

• Guest- Dr. Amar Chakrabortya, MD

53:!2- Abstract #9. Disparity in immune-mediated reactions to Crotalidae polyvalent immune fab (ovine) and Crotalidae immune F(ab’)2 [equine] in alpha-gal endemic regions and alpha-gal sensitized adults

• Guest- Dr. Ari Filip, MD

59:10- Abstract # 26. Acute propranolol overdose and dose thresholds of severe toxicity

• Guest- Dr. Katherine Isoardi, MBBS

1:06:05- 28. Risk of serotonin toxicity following acute lamotrigine overdose

• Guest- Dr. Angela Chiew, MBBS, PhD (Introduction at 1:00:00)

1:12:36- Interview with AACT President Elect

• Guest- Dr. Jillian Theobald, MD, PhD

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In this episode the poison lab hosts scientific discourse . Three listeners (Dr. Michael Mullins, Dr. Donna Seger, and Dr. Leon Gussow) write in their critiques surrounding specific recommendations and language used with the AHA 2023 Management of Poisoning Cardiac Arrest or Life-Threatening Toxicity guidelines. Lead author of the guidelines Dr. Eric Lavonas then responds to and addresses their points with counterpoints or appraisals. Tune in and draw your own conclusions!

• Link to guidelines
• Link to high yield review 

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Have a burning question you have always wanted to ask a toxicologist? What are tips for managing an anticholinergic overdose? What is the deadliest poison? Why are they called lead pencils if there is no lead?! Send your questions in to [email protected] to take part in a future episode! (If you would like to be anonymous simply state it in the email)

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In this episode Ryan is joined by two expert guests to help read listener guesses for the cause of this poisoning murder and shed light on the toxin involved in the case, which puzzled medicolegal investigators. Ryan is joined by Dr. Dan McCabe, MD (emergency medicine physician, medical toxicologist, medical director of Iowa poison center) and Dr. Crissy Lawson PharmD (emergency medicine pharmacist). 

• SPOLIER ALERT
•  Mystery case from the show
• Review Paper from Dr's  Lawson, McCabe, and Feldman (PMID: 38613376)
• Toxo's show note references

1. TV special about Mary Yoder colchicine murder
2. Colchicine potential arrhythmic effects
3. Go fund me for Dr. Betty Bowman 

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