Farshad Shirazi

Interests

Research

Medication's interactions, adverse effect of medicines, drugs of abuse and performance enhancing agents in man. New antivenom and antidotes. Public health impact of occupational and environmental exposures.

Teaching

Medical toxicology and clinical pharmacology, geriatric pharmacology, public health and preparedness, occupational/environmental exposures, hazardous materials, therapeutic effects, medication's interactions, adverse effect of medicines, drugs of abuse and performance enhancing agents in man. Toxicology and clinical effects of bites and stings.

Courses

No activities entered.

Scholarly Contributions

Books

• Shirazi, F., Young, R., & Kim-Ley, M. (2014). Top Pediatric Problem, Toxicologic Emergencies. EMRA.

Chapters

• Shirazi, F., Mehrpour, O., & Nakahee, S. (2024).

  Cyclosarin (GF)

  . In Encyclopedia of Toxicology (Fourth Edition)(pp 423-431, Vol. 3,). Phoenix, AZ: Elsevier Inc. American College of Medical Toxicology (ACMT). doi:978012824315 / ISBN 978-0-323-85434-4
• Shirazi, F., Mehrpour, O., & Ateai, M. (2023). Ricin and other Toxalbumins. In Encyclopedia of Toxicology Reference Work (Fourth Edition)(pp 295-303, Vol. 8,). San Diego, CA: Elsevier Inc. / American College of Medical Toxicology (ACMT). doi:10.1016/B978-0-12-824315-2.00948-9
• Shirazi, F., Keith, B. J., Kelly, G. A., & Nicholas, H. B. (2019). Chapter SC10: Exotic Nonnative Snake Envenomations

  . In Goldfrank's Toxicology Emergencies(pp 1633-1638). 11th Edition, Natural Toxins and Envenomations: Goldfrank's Toxicology Emergencies.

• Hurst, N., Sloan, C. T., French, R., Karpen, S. R., & Shirazi, F. (2016). Critical Care Pharmacotherapy. In American College of Clinical Pharmacology(pp 781-792). Chapter 38, Medication Withdrawal in the Intensive Care Unit: American College of Clinical Pharmacy.
• Huffman, R., Boesen, K. J., Green Boesen, K. A., & Shirazi, F. (2015). SP 8 - Exotic Nonnative Snake Envenomation. In Goldfrank's Toxicologic Emergencies, 10th Edition. New York: PP McGraw Hill Education.
• Woosley, R. L., Shirazi, F., & Shirazi, F. (2007). Clinical Pharmacology of Antiarrhythmic Drugs. In Cardiovascular Therapeutics A Companion to Braunwald's Heart Disease Third Edition • 2007(pp 433-446). Section 4: Arrhythmias/Conduction Disturbances; Chapter 19 -: Elsevier Inc. doi:10.1016/B978-1-4160-3358-5.50025-5

Journals/Publications

• Gaither, J. B., French, R., Knotts, M., Lerman, M., Harrell, A. J., McIntosh, S., Rice, A. D., Cole, R., Gilmore, S., Hindman, D. E., Edwards, C., Nguyn, H. N., Truxillo, M., West, J., Yeoh, A., David, T., Shirazi, F. M., Wilson, B. Z., Debevec, J. T., , Schertz, M., et al. (2025).

  Consensus Guideline for the Care of Patients in the Prehospital and Aerospace Settings with Exposures to Hydrazine and Hydrazine Derivatives

  . Prehospital Emergency Care, Epub ahead of print, 1-9. doi:10.1080/10903127.2024.2442097
• Guthrie, A. M., Smelski, G., Maciulewicz, T., & Shirazi, F. M. (2024).

  A case report of mis-snaken identity: When misdiagnosis really bites

  . Toxicon : official journal of the International Society on Toxinology, 248, 108032. doi:10.1016/j.toxicon.2024.108032
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  When patients present with an unknown puncture wound, emergency physicians need to consider regional hazards, in addition to standard mechanical injury etiologies. In the Southwestern United States, one such hazard is the rattlesnake. In this report, we present a case in which a rattlesnake envenomation was not considered as a possible cause for a puncture wound of unknown origin, which resulted in an envenomation left untreated for 7 days. A full dry bite observation period of 12 h with serial physical exams and laboratory analysis with guidance from the region poison control center might have led to earlier recognition of an envenomation and antivenom administration. A male patient in his late 70's felt a painon his right ankle while in his backyard in southern Arizona. He did not see the cause and assumed he had sustained an insect bite. He went to the ED that day with minor pain and swelling and was discharged home. One week later, he re-presented severely anemic with edema and ecchymosis to the entire right lower extremity that developed over several days after his first ED visit. He was admitted for antivenom and blood transfusion and discharged on hospital day three. For as long as humans continue to interact with the natural world, venomous creature encounters are going to continue to happen. Rattlesnake envenomation should be included in a physician's differential diagnosis even if one is not witnessed, especially in regions with high rattlesnake activity. In addition to assessing for other potential causes of undifferentiated puncture wounds, serial physical examinations and laboratory testing (with guidance of the regional poison center) are necessary to rule out rattlesnake envenomation.
• Klotz, S. A., Smelski, G. T., Watkins, S. A., & Shirazi, F. M. (2024).

  Infections following rattlesnake envenomation and use of antibiotics

  . Transactions of the Royal Society of Tropical Medicine and Hygiene. doi:org/10.1093/trstmh/trae044
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  There are 7000-8000 venomous snake bites annually in the USA. Antibiotics are commonly administered to bite victims because infection is difficult to differentiate from local tissue injury following envenomation.
• L Mitchell, C., Smelski, G., Schmid, K., Roland, M., Christenberry, M., D Ellingson, K., Brooks, D. E., Komatsu, K., Dudley, S., Shirazi, F., & Cullen, T. A. (2024).

  Characterization of patients with a snakebite presenting to healthcare facilities and reported to poison and drug information centers-Arizona, 2017-2021

  . Clinical toxicology (Philadelphia, Pa.), 62(11), 754-761. doi:10.1080/15563650.2024.2402937
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  Envenomation after a North American rattlesnake ( spp. and spp.) bite is associated with substantial morbidity. Arizona reports the highest number of rattlesnake envenomations annually in the United States. We evaluated the performance of poison and drug information centers for snakebite surveillance, compared with the hospital and emergency department discharge database. We used both datasets to improve the characterization of epidemiology, healthcare costs, and clinical effects of snakebite envenomations in Arizona.
• Maciulewicz, T. S., Axon, D. R., & Shirazi, F. M. (2024).

  Characterization of hypofibrinogenemia following rattlesnake envenomation treated with crotalidae immune F(ab') (equine) antivenom

  . Clinical toxicology (Philadelphia, Pa.), 62(11), 749-753. doi:10.1080/15563650.2024.2406427
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  Hemotoxicity is common following rattlesnake envenomation. Published experiences with equine-derived crotalidae immune F(ab') antivenom have characterized hemotoxicity as delayed, recurrent, or persistent. This study investigated recovery of hypofibrinogenemia following rattlesnake envenomation treated with equine-derived crotalidae immune F(ab') antivenom.
• Maciulewicz, T. S., Cardwell, M. D., Brandecker, K., Massey, D. J., & Shirazi, F. M. (2024).

  Snake eyes: Characterization of topical ocular exposures from rattlesnakes in Arizona

  . Toxicon : official journal of the International Society on Toxinology, 244, 107775. doi:10.1016/j.toxicon.2024.107775
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  Patients occasionally present with reports of ocular exposure to fluids from rattlesnakes, claiming or suspecting the substance to be venom. This study set out to evaluate and characterize reported cases of suspected venom-induced ophthalmia in humans. A retrospective review of rattlesnake exposures reported to the Arizona Poison and Drug Information Center over a 24-year period was conducted for ocular exposures. Recorded information included patient demographics, clinical course, laboratory results, and treatments. Documentation regarding interactions between patients and snakes was reviewed by Arizona Poison and Drug Information Center herpetologists to evaluate what substance was expelled from the snake resulting in ocular exposure. Our review of rattlesnake encounters found a total of 26 ocular exposure cases. Patient demographics were largely intentional interactions and involved the male sex. Symptoms ranged from asymptomatic to minor effects with 46.2% managed from home and treated with fluid irrigation. A review of cases by herpetologists concluded the exposure patients commonly experienced was to snake musk. Kinematics of venom expulsion by rattlesnakes conclude the venom gland must be compressed, fangs erected to ≥60, and fang sheath compressed against the roof of the mouth for venom expulsion. Evidence suggests the chance of venom "spitting" by rattlesnakes is close to zero. Rattlesnakes are documented to forcefully expel airborne malodorous "musk" defensively. An important distinction to remember is musk has a foul odor and is usually colorless, while venom is comparatively odorless and yellow. Rattlesnake venom-induced ophthalmia is a rare event as venom expulsion requires the kinematics of feeding or defensive bites. If the rattlesnake is not in the process of biting or otherwise contacting some other object with its mouth, it is more biologically plausible patients are being exposed to snake musk as a deterrent. Whether it's venom or musk, topical exposure to the eyes should prompt immediate irrigation.
• Nakamura, H., Maciulewicz, T., Ramirez, J., Hughes, B., Axon, D. R., Shirazi, F., & Smelski, G. (2024).

  Twenty-five years of suspected rattlesnake encounters in Arizona

  . Clinical toxicology (Philadelphia, Pa.), 62(8), 526-532. doi:10.1080/15563650.2024.2380439
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  Rattlesnake ( spp spp.) bites in the southwestern United States are associated with significant morbidity. This study aims to describe 25 years of rattlesnake encounters reported to the Arizona Poison and Drug Information Center to identify vulnerable populations and circumstances where encounters occur to create public education to reduce future bites.
• Whalen, M., Aizenberg, A., Shirazi, F., Berrigan, J., & Walter, F. (2024).

  Skin decontamination with and without water irrigation

  . Disaster Medicine and Public Health Preparedness, 18. doi:10.1017/dmp.2024.118
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  Objective: Rinsing only with water or washing with soap and water are common methods of skin decontamination for skin contaminated during a chemical hazard release. The null hypothesis was that a 15-minute water irrigation (decontamination method 1) would not be superior to decontamination using a microfiber towel, followed by a wet wipe (Signature Select Softly Flushable Tissue Better Living Brands LLC, Pleasanton, CA), followed by using another microfiber towel (decontamination method 2). Methods: A simulated contaminant (Magic Fluorescent Glow Paint for Face and Body, iLC Shenzhen Fulimei Technology Co. LTD, Shenzhen, the People’s Republic of China) was applied to the dorsal skin of each subject’s forearms. Then, photographs of these subject’s skin were taken before and after decontamination of the simulated contaminant by using either decontamination method 1 or 2. Each of the subjects underwent both decontamination methods in separate trials, with each subject using one forearm for decontamination method 1 and their other forearm for decontamination method 2. Discrete points of contamination were quantified on the photographs that were taken with the skin illuminated by ambient visible light or ultraviolet light (395nm, Roceei ultraviolet flashlight, China). Results: Under visible light, no residual contamination was seen by inspecting photographs taken after decontaminating with either method. Under ultraviolet light, less visible contamination was seen by inspecting photographs taken after decontaminating with method 1 than after decontaminating with method 2. Conclusion: In this study, skin decontamination with water irrigation was superior to skin decontamination without water irrigation.
• Dehghani, R., Monzavi, S. M., Mehrpour, O., Shirazi, F. M., Hassanian-Moghaddam, H., Keyler, D. E., Wüster, W., Westerström, A., & Warrell, D. A. (2023). Medically important snakes and snakebite envenoming in Iran. Toxicon : official journal of the International Society on Toxinology, 230, 107149. doi:10.1016/j.toxicon.2023.107149
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  Snakebite is a relatively common health condition in Iran with a diverse snake fauna, especially in tropical southern and mountainous western areas of the country with a plethora of snake species. The list of medically important snakes, circumstances and effects of their bite, and necessary medical care require critical appraisal and should be updated regularly. This study aims to review and map the distributions of medically important snake species of Iran, re-evaluate their taxonomy, review their venomics, describe the clinical effects of envenoming, and discuss medical management and treatment, including the use of antivenom. Nearly 350 published articles and 26 textbooks with information on venomous and mildly venomous snake species and snakebites of Iran, were reviewed, many in Persian (Farsi) language, making them relatively inaccessible to an international readership. This has resulted in a revised updated list of Iran's medically important snake species, with taxonomic revisions of some, compilation of their morphological features, remapping of their geographical distributions, and description of species-specific clinical effects of envenoming. Moreover, the antivenom manufactured in Iran is discussed, together with treatment protocols that have been developed for the hospital management of envenomed patients.
• Dudley, S., Klotz, S. A., Schmidt, J. O., Shirazi, F. M., Smith, S. L., & Yates, S. (2023).

  Antivenom for Severe Scorpion Envenomation in Arizona

  . New England Journal of Medicine, 388(9), 853-854. doi:10.1056/nejmc2029813
• Mehrpour, O., Saeedi, F., Vohra, V., Abdollahi, J., Shirazi, F. M., & Goss, F. (2023). The role of decision tree and machine learning models for outcome prediction of bupropion exposure: A nationwide analysis of more than 14 000 patients in the United States. Basic & clinical pharmacology & toxicology, 133(1), 98-110. doi:10.111/bcpt.13865
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  Bupropion is widely used for the treatment of major depressive disorder and for smoking cessation assistance. Unfortunately, there are no practical systems to assist clinicians or poison centres in predicting outcomes based on clinical features. Hence, the purpose of this study was to use a decision tree approach to inform early diagnosis of outcomes secondary to bupropion overdose. This study utilized a dataset from the National Poison Data System, a 6-year retrospective cohort study on toxic exposures and patient outcomes. A machine learning algorithm (decision tree) was applied to the dataset using the sci-kit-learn library in Python. Shapley Additive exPlanations (SHAP) were used as an explainable method. Comparative analysis was performed using random forest (RF), Gradient Boosting classification, eXtreme Gradient Boosting, Light Gradient Boosting (LGM) and voting ensembling. ROC curve and precision-recall curve were used to analyse the performance of each model. LGM and RF demonstrated the highest performance to predict outcome of bupropion exposure. Multiple seizures, conduction disturbance, intentional exposure, and confusion were the most influential factors to predict the outcome of bupropion exposure. Coma and seizure, including single, multiple and status, were the most important factors to predict major outcomes.
• Shirazi, F. M., Nejatian, A., Sadabad, F. E., Nejati, S. F., Nakhaee, S., & Mehrpour, O. (2023). How much natural ventilation rate can suppress COVID‑19 transmission in occupancy zones?. Journal of Research in Medical Sciences 10.4103/jrms.jrms_796_22;. doi:10.4103/jrms.jrms_796_22;
• Alsultan, R., Brody, J., Hurst, N., Welch, S., & Shirazi, M. (2022). Wessel's tiger ornamental tarantula bite envenomation: A case report and venom analysis. Toxicon : official journal of the International Society on Toxinology, 223, 107013. doi:https://doi.org/10.1016/j.toxicon.2022.107013
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  Tarantulas are commonly kept as pets and bites from some species can cause severe symptoms. Here we describe a case of a patient with transient atrial fibrillation (afib) and painful muscle cramps requiring hospitalization for pain management after being bitten by a Poecilotheria tigrinawesseli (Wessel's Tiger Ornamental) spider. He was discharged with a cardiac event monitor and outpatient cardiology follow-up. The event monitor documented transient afib which decreased in frequency then resolved halfway through the three-week monitoring period. In conclusion, tarantula envenomation is usually mild with local pain and edema most reported. However, bites by some species, such as P. tigrinawesseli may have local and more systemic, long-lasting effects.
• Ataei, M., Shirazi, F. M., Nakhaee, S., Abdollahi, M., & Mehrpour, O. (2022). Assessment of cloth masks ability to limit Covid-19 particles spread: a systematic review. Environmental Science and Pollution Research International, 29(2), 1645-1676. doi:10.1007/s11356-021-16847-2
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  After the spread of Covid 19 worldwide, the use of cloth masks increased significantly due to a shortage of medical masks. Meanwhile, there were different opinions about the effectiveness of these masks and, so far, no study has been done to find the best fabric masks. This study reviews and summarizes all studies related to fabric masks' effectiveness and various fabrics against coronavirus. This systematic review is based on PRISMA rules. Two researchers separately examined three databases: PubMed, Scopus, and Web of Science. Laboratory and clinical studies were included. After extracting the articles, their quality was assessed with the Joanna Briggs Institute (JBI) tool. In addition to efficacy, other factors, including the penetration of masks, pressure drop, and quality factor, were examined to select the best fabrics. Of the 42 studies selected, 39 were laboratory studies, and 3 were clinical studies. Among the various fabrics examined, cotton quilt 120 thread per inch (TPI), copy paper (bonded), hybrid of cotton with chiffon/ silk, and flannel filtration were found to have over 90% effectiveness in the particle size range of Covid-19. The results and comparison of different factors (pressure drop, filtration efficacy, penetration, filtration quality, and fit factor have been evaluated) showed that among different fabrics, hybrid masks, 2-layered cotton quilt, 2-layered 100% cotton, cotton flannel, and hairy tea towel + fleece sweater had the best performance. Clinical studies have not explicitly examined cloth masks' effectiveness in Covid-19, so the effectiveness of these types of masks for Covid 19 is questionable, and more studies are needed.
• Carter, R. W., Gerardo, C. J., Samuel, S. P., Kumar, S., Kotehal, S. D., Mukherjee, P. P., Shirazi, F. M., Akpunonu, P. D., Bammigatti, C., Bhalla, A., Manikath, N., Platts-Mills, T. F., & Lewin, M. R. (2022). The BRAVO Clinical Study Protocol: Oral Varespladib for Inhibition of Secretory Phospholipase A2 in the Treatment of Snakebite Envenoming. Toxins, 15(1), 22. doi:10.3390/toxins15010022
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  Snakebite is an urgent, unmet global medical need causing significant morbidity and mortality worldwide. Varespladib is a potent inhibitor of venom secretory phospholipase A (sPLA) that can be administered orally via its prodrug, varespladib-methyl. Extensive preclinical data support clinical evaluation of varespladib as a treatment for snakebite envenoming (SBE). The protocol reported here was designed to evaluate varespladib-methyl for SBE from any snake species in multiple geographies.
• Edwards, C. J., Ng, V., Hurst, N. B., Contreras, J., & Shirazi, F. M. (2022). Pharmacy Calls for Prescription Clarification at an Academic Emergency Department. The Journal of emergency medicine, 62(6), 783-788. doi:10.1016/j.jemermed.2022.01.005
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  Approximately two-thirds of patients discharged from an emergency department (ED) are prescribed at least one medication. Prescription clarification by outpatient pharmacies for ED patients can lead to delays for patients and added workload.
• Hassanian-Moghaddam, H., Monzavi, S. M., Shirazi, F. M., Warrell, D. A., & Mehrpour, O. (2022). First report of a confirmed case of Montivipera latifii (Latifi's viper) envenoming and a literature review of envenoming by Montivipera species. Toxicon : official journal of the International Society on Toxinology, 207, 48-51. doi:10.1016/j.toxicon.2021.12.020
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  Latifi's viper (Montivipera latifii), also known as Lar Valley or Damavandi viper, is endemic to Iran. It has rarely been recorded, as it occurs in a highly-protected national park. In this first clinical report of a confirmed bite by this species, a teenage girl was bitten on the chin, causing rapidly-progressive swelling of the face and oropharyngeal mucosa. At a local hospital, a misleading history given by the patient's relatives of a wasp sting and inadequate inspection of the bite wound misled the physicians from making the correct diagnosis, resulting in a considerable delay in the administration of antivenom. This allowed the development of partial obstruction of the upper airway causing respiratory distress. After transfer to a tertiary hospital, attempts at endotracheal intubation failed, necessitating tracheostomy, but this was not implemented early enough to prevent her developing respiratory failure and losing consciousness. After she was stabilized, snakebite envenoming was diagnosed by a clinical toxicologist who observed two fang puncture marks on her chin. This was later confirmed when a snake, identified as M. latifii, was discovered at the room where the bite had occurred. Her facial swelling and ecchymosis, attributable to envenoming, were effectively controlled by high-dose antivenom therapy. However, she did not recover consciousness, remaining in a vegetative state. About three weeks after the bite, she died as an indirect result of hypoxic brain damage complicated by septicemia. Prompt diagnosis, relief of upper airway obstruction and timely antivenom therapy might have prevented this tragic fatal outcome.
• Mehrpour, O., Hoyte, C., Goss, F., Shirazi, F. M., & Nakhaee, S. (2022). Decision tree algorithm can determine the outcome of repeated supratherapeutic ingestion (RSTI) exposure to acetaminophen: review of 4500 national poison data system cases. Drug and Chemical Toxicology, 1-7. doi:10.1080/01480545.2022.2083149
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  This study is aimed at establishing the outcome of RSTI exposure to acetaminophen based on a decision tree algorithm for the first time. This study used the National Poison Data System (NPDS) to conduct a six-year retrospective cohort analysis, which included 4522 individuals. The patients had a mean age of 26.75 ± 16.3 years (1-89). 3160 patients (70%) were females. Most patients had intentional exposure to acetaminophen. Almost all the patients had acetaminophen exposure via ingestion. In addition, 400 (8.8%) experienced major outcomes, 1500 (33.2%) experienced moderate outcomes, and 2622 (58%) of the patients experienced mild ones. The decision tree model performed well in the training and test groups. In the test group, the accuracy was 0.813, precision of 0.827, recall being 0.798, specificity 0.898, and an F1 score 0.80. In the training group, accuracy was 0.831, recall was 0.825, precision was 0.837, specificity was 0.90, and F1 score was 0.829. Our results showed that serum liver enzymes being present at elevated levels (Alanine aminotransferase (ALT), Aspartate aminotransferase (AST) greater than 1000 U/L followed by ALT, AST between 100 and 1000 U/L) , prothrombin time (PT) prolongation, bilirubin increase, renal failure, confusion, age, hypotension, other coagulopathy (such as partial thromboplastin time (PTT) prolongation), acidosis, and electrolyte abnormality were the effective factors in determining the outcomes in these patients. The decision tree algorithm is a dependable method for establishing the prognosis of patients who have been exposed to RSTI acetaminophen and can be used throughout the patients' hospitalization period.
• Mehrpour, O., Saeedi, F., Hoyte, C., Goss, F., & Shirazi, F. M. (2022). Correction: Utility of support vector machine and decision tree to identify the prognosis of metformin poisoning in the United States: analysis of National Poisoning Data System. BMC pharmacology & Toxicology, 23(1), 68. doi:https://doi.org/10.1186/s40360-022-00588-0
• Pourbagher-Shahri, A. M., Schimmel, J., Shirazi, F. M., Nakhaee, S., & Mehrpour, O. (2022). Use of fomepizole (4-methylpyrazole) for acetaminophen poisoning: A scoping review. Toxicology letters, 355(1), 47-61. doi:10.1016/j.toxlet.2021.11.005
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  Acetaminophen (paracetamol, APAP) poisoning is a prominent global cause of drug-induced liver injury. While N-acetylcysteine (NAC) is an effective antidote, it has therapeutic limitations in massive overdose or delayed presentation. The objective is to comprehensively review the literature on fomepizole as a potential adjunct antidote for acetaminophen toxicity.
• Shirazi, F. M., Mirzaei, R., Nakhaee, S., Nejatian, A., Ghafari, S., & Mehrpour, O. (2022). Repurposing the drug, ivermectin, in COVID-19: toxicological points of view. European Journal of Medical Research, 27(1), 21. doi:10.1186/s40001-022-00645-8
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  The global COVID-19 pandemic has affected the world's population by causing changes in behavior, such as social distancing, masking, restricting people's movement, and evaluating existing medication as potential therapies. Many pre-existing medications such as tocilizumab, ivermectin, colchicine, interferon, and steroids have been evaluated for being repurposed to use for the treatment of COVID-19. None of these agents have been effective except for steroids and, to a lesser degree, tocilizumab. Ivermectin has been one of the suggested repurposed medications which exhibit an in vitro inhibitory activity on SARS-CoV-2 replication. The most recommended dose of ivermectin for the treatment of COVID-19 is 150-200 µg/kg twice daily. As ivermectin adoption for COVID-19 increased, the Food and Drug Administration (FDA) issued a warning on its use during the pandemic. However, the drug remains of interest to clinicians and has shown some promise in observational studies. This narrative reviews the toxicological profile and some potential therapeutic effects of ivermectin. Based on the current dose recommendation, ivermectin appears to be safe with minimum side effects. However, serious questions remain about the effectiveness of this drug in the treatment of patients with COVID-19.
• Smelski, G., Shirazi, F. M., Massey, D. J., Maciulewicz, T., Dudley, S., & Cardwell, M. D. (2022). Fashionably late: A characterization of late coagulopathies in rattlesnake envenomations between Fab and F(ab')2 antivenoms.. Toxicon, 212, 49-54. doi:10.1016/j.toxicon.2022.03.017
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  Rattlesnake envenomation may lead to a multitude of clinical effects, including a late onset hemorrhage. Laboratory values such as platelets and fibrinogen are commonly used to assess the risk of developing a life-threatening bleed. To date, no specific threshold has been identified that links a lab value to the risk of bleeding. This has led to widespread practice variability among clinicians managing snake bites. In assessing risk for patients, we apply the concept that the more abnormal the lab values are, the higher the risk probably is. Late onset coagulopathies pose a unique clinical challenge because they indicate the potential risk for a life-threatening hemorrhage, yet they have been identified after hospital discharge. There are currently two antivenom (AV) products on the US market to treat rattlesnake envenomations, a Fab product, CroFab® (BTG, UK) and a F (ab')2 product, Anavip® (Bioclon, Mexico)..This study intended to characterize the incidence and severity of late coagulopathies reported to a Regional Poison Center (RPC) and hypothesized that late coagulopathies occur at rates higher than previously reported in the literature. Additionally, we sought to compare rates of late coagulopathy between Fab and F (ab')2 AV..The investigators performed an in-depth review of all suspected snakebite envenomations from 2018 to 2020 that presented to an Arizona healthcare facility in the RPC's catchment area between January 2018 through December of 2020. Patients were excluded from analysis if they did not receive any antivenom, had an incomplete medical record with the APDIC, were diagnosed as something other than a rattlesnake bite or had a known medical history that clouded the diagnosis or assessment of a rattlesnake envenomation..In total, 522 records were reviewed of which 283 patients met the inclusion criteria. There were 149 patients who received Fab AV and 134 who received F (ab')2. No significant baseline or demographic differences existed between the groups. 95 of the 283 patients developed a late onset coagulopathy. 39% of the late onset coagulopathies were delayed, 32% were recurrent and 29% were persistent. When comparing the two different AV products, delayed or recurrent coagulopathies occurred in 36% of Fab AV- and 10% of F (ab')2 treated patients. Persistent coagulopathies occurred in 17% of Fab AV- and 8% of F (ab')2 treated patients. Interestingly, there were zero cases of late hypofibrinogenemia in any of the 134 F (ab')2 treated patients compared to 26% of all Fab treated ones. The average onset of late coagulopathy post-bite was 8 days for Fab AV and 7 for F (ab')2..The results from this study suggest the total rate of late onset coagulopathies may be underestimated. Additionally, our results suggest the potential that F (ab')2 AV may be associated with fewer late onset coagulopathies, especially late onset hypofibrinogenemia.
• Wilson, B. Z., Bahadir, A., Andrews, M., Karpen, J., Winkler, G., Smelski, G., Dudley, S., Walter, F. G., & Shirazi, F. M. (2022). Initial Experience with F(ab')2 Antivenom Compared with Fab Antivenom for Rattlesnake Envenomations Reported to a single poison center during 2019. Toxicon : official journal of the International Society on Toxinology, 209, 10-17. doi:10.1016/j.toxicon.2022.01.007
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  There are two Food and Drug Administration (FDA)-approved antivenoms available for rattlesnake envenomations in the United States: the equine-derived F (ab')2 product sold with the brand name Anavip (F (ab')2 AV) and the ovine-derived Fab product sold with the brand name Crofab (FabAV).
• Farkhondeh, T., Roshanravan, B., Shirazi, F. M., & Mehrpour, O. (2021). Can dantrolene be used in the treatment of cardioglycosides poisonings?. Expert Opinion on Drug Metabolism & Toxicology, 17(1), 1-2. doi:10.1080/17425255.2021.1843632
• Holzman, S. D., Larsen, J., Kaur, R., Smelski, G., Dudley, S., & Shirazi, F. M. (2021). Death by hand sanitizer: syndemic methanol poisoning in the age of COVID-19. Clinical Toxicology (Philadelphia, Pa.), 59(11), 1009-1014. doi:10.1080/15563650.2021.1895202
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  The advent of COVID-19 increased attention to hand hygiene in prevention of disease transmission. To meet the increased demand for hand sanitizer during the pandemic, the US FDA issued an Emergency Use Authorization allowing new manufacturers and importers to enter the market. Some of the newly introduced hand sanitizer products contained methanol in lieu of ethanol or isopropanol. We describe five patients with fatal methanol poisoning resulting from hand sanitizers improperly containing methanol.
• Klotz, S. A., Miller, M. L., Pogreba-Brown, K. M., Komatsu, K. K., Morehouse, L. M., Dudley, S. W., & Shirazi, F. M. (2021). e-Health for COVID-19 Epidemic: The Arizona Poison and Drug Information Center Experience. Telemedicine Journal and e-Health: the Official Journal of the American Telemedicine Association, 28(5), 747-751. doi:10.1089/tmj.2021.0287
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  A significant challenge of the COVID-19 epidemic was the dissemination of accurate and timely information to the public, health care providers, and first responders. We describe the expansion of the Arizona Poison and Drug Information Center (APDIC) to fill such a need for residents of Arizona. The original mission of the APDIC was recognition and management of chemical exposure, poisoning, envenomation, and drug-related medical problems. In response to COVID-19, APDIC expanded its personnel and facilities to accommodate telephone calls and teleconsults regarding COVID-19. Thirteen different topics dealing with COVID-19 were addressed and tracked and included: testing information, isolation, prevention, personal protective equipment, travel, vaccines, therapies, antibody testing, contact tracing, exposure to the virus and what to do in businesses, at work or at school regarding isolation and quarantine. Responding to the public health needs, APDIC accepted >320,000 telephone calls and completed 48,346 teleconsults from March 3, 2020 to March 3, 2021. This represented a 15-fold increase in calls and twice the number of consults over 2019. Upon release of the vaccine, calls increased sharply with >7,000 calls in 1 day (February 7, 2021). In conclusion, the APDIC, rapidly expanded to address urgent public health information needs surrounding COVID-19 while still accomplishing its founding mission.
• Klotz, S. A., Yates, S., Smith, S. L., Dudley, S., Schmidt, J. O., & Shirazi, F. M. (2021). Scorpion Stings and Antivenom Use in Arizona. The American Journal of Medicine, 134(8), 1034-1038. doi:10.1016/j.amjmed.2021.01.025
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  Arizona's rugged desert landscape harbors many venomous animals, including a small nocturnal scorpion, Centruroides sculpturatus, whose venom can cause severe neuromotor disturbance. An effective antivenom is available at selected health care facilities in the state.
• Mehrpour, O., Modi, M., Mansouri, B., Azadi, N. A., Nakhaee, S., Amirabadi, A., Anaei-Sarab, G., Shirazi, F. M., & Weiss, S. T. (2021). Comparison of Vitamin B12, Vitamin D, and Folic Acid Blood Levels in Plumbism Patients and Controls in Eastern Iran. Biological Trace Element Research, 199(2), 813. doi:10.1007/s12011-02-02189
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  The aim of this study was to evaluate the blood levels of folic acid, vitamin B12, and 25-hydroxyvitamin D (25-OHD) in patients with lead poisoning compared with control subjects in Eastern Iran. This analytical case-control study was conducted on 40 lead-poisoned patients who were referred to Imam Reza Hospital in Birjand from 2018 to 2019. Blood samples were collected from an additional 40 individuals without lead poisoning as a control group. The results indicated that the mean vitamin B12, vitamin D, and folic acid levels for the case group were 356.5 ± 200.1 pg/ml, 24.38 ± 9.5 ng/ml, and 7.4 ± 3.7 ng/ml, respectively. Mean folic acid level in the case group was significantly lower than control group (7.4 ng/ml vs. 12.70 pg/ml, P = 0.001), whereas the mean of the vitamin D levels at the case group was significantly higher than that of the control group (24.3 ng/ml vs. 20.1 ng/ml, P = 0.03). Moreover, mean vitamin B12 levels were significantly lower in the case group in comparison with the control group (356.5 pg/ml vs. 500.8 pg/ml) (P 
• Mhayamaguru, K. M., Gaither, J. B., French, R. N., Christopher, N. D., Waters, K. E., Jado, I., Rice, A. D., Beskind, D., Knotts, M. C., Ronnebaum, J. A., Smith, J. J., & Walter, F. G. (2021). Availability and Use of Medications by Prehospital Providers Trained to Manage Medical Complications of Patients in Hazardous Materials Incidents. American Journal of Disaster Medicine, 16(3), 215-223. doi:https://doi.org/10.5055/ajdm.2021.0404
• Pasha, A. K., Clements, C. Y., Reynolds, C. A., Lopez, M. K., Lugo, C. A., Gonzalez, Y., Shirazi, F. M., & Abidov, A. (2021). Cardiovascular Effects of Medical Marijuana: A Systematic Review. The American Journal of Medicine, 134(2), 182-193. doi:org/10.1016/j.amjmed.2020.09.015
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  Utilization of marijuana as a medicinal agent is becoming increasingly popular, and so far, 25 states have legalized it for medical purposes. However, there is emerging evidence that marijuana use can result in cardiovascular side effects, such as rhythm abnormalities, syncope/dizziness, and myocardial infarction, among others. Further, there are currently no stringent national standards or approval processes, like Food and Drug Administration (FDA) evaluation, in place to assess medical marijuana products. This review includes the largest up-to-date pooled population of patients with exposure to marijuana and reported cardiovascular effects. Although purported as benign by many seeking to advance the use of marijuana as an adjunctive medical therapy across the country, marijuana is associated with its own set of cardiovascular risks and deserves further definitive study and the same level of scrutiny we apply in research of all other types of medications. When used as a medicinal agent, marijuana should be regarded accordingly, and both clinical providers and patients must be aware of potential adverse effects associated with its use for early recognition and management.
• Rinner, G. R., Watkins, S. A., Shirazi, F., Fernandez, M. C., Hess, G., Mihalic, J., Runcorn, S., Waddell, V., Ritter, J., Reagan-Steiner, S., Thomas, J., Yip, L., & Walter, F. G. (2021). Fatal abrin poisoning by injection. Clinical Toxicology, 59(2), 169-171. doi:10.1080/15563650.2020.1771360
• Samarghandian, S., Shirazi, F. M., Saeedi, F., Roshanravan, B., Pourbagher-Shahri, A. M., Khorasani, E. Y., Farkhondeh, T., Aaseth, J. O., Abdollahi, M., & Mehrpour, O. (2021). A systematic review of clinical and laboratory findings of lead poisoning: lessons from case reports. Toxicology and applied pharmacology, 429, 115681. doi:10.1016/j.taap.2021.115681
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  Lead is one of the most toxic heavy metals in the environment. The present review aimed to highlight hazardous pollution sources, management, and review symptoms of lead poisonings in various parts of the world. The present study summarized the information available from case reports and case series studies from 2009 to March 2020 on the lead pollution sources and clinical symptoms. All are along with detoxification methods in infants, children, and adults. Our literature compilation includes results from 126 studies on lead poisoning. We found that traditional medication, occupational exposure, and substance abuse are as common as previously reported sources of lead exposure for children and adults. Ayurvedic medications and gunshot wounds have been identified as the most common source of exposure in the United States. However, opium and occupational exposure to the batteries were primarily seen in Iran and India. Furthermore, neurological, gastrointestinal, and hematological disorders were the most frequently occurring symptoms in lead-poisoned patients. As for therapeutic strategies, our findings confirm the safety and efficacy of chelating agents, even for infants. Our results suggest that treatment with chelating agents combined with the prevention of environmental exposure may be an excellent strategy to reduce the rate of lead poisoning. Besides, more clinical studies and long-term follow-ups are necessary to address all questions about lead poisoning management.
• Shirazi, F. (2021). Use of Crotalidae equine immune F(ab’)₂ antivenom for treatment of an Agkistrodon envenomation. Clinical Toxicology, 59(11), 1023-1026. doi:10.1080/15563650.2021.1892718
• Wilson, B. Z., Larsen, J., Smelski, G., Dudley, S., & Shirazi, F. M. (2021). Use of Crotalidae equine immune F(ab') antivenom for treatment of an envenomation. Clinical Toxicology (Philadelphia, Pa.), 59(11), 1023-1026. doi:10.1080/15563650.2021.1892718
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  Anavip (F(ab')AV) is a lyophilized F(ab') immunoglobulin fragment derived from horses immunized with venom from and . It was approved by the FDA in 2015 for treatment of North American rattlesnake envenomation but not for envenomation. Published data regarding the efficacy and safety of Anavip in treating envenomations is limited. We present a case of a patient treated with Anavip after confirmed envenomation.
• Ataei, M., Shirazi, F. M., Lamarine, R. J., Nakhaee, S., & Mehrpour, O. (2020). A double-edged sword of using opioids and COVID-19: a toxicological view. Substance abuse treatment, prevention, and policy, 15(1), 91.
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  Today, COVID-19 is spreading around the world. Information about its mechanism, prognostic factors, and management is minimal. COVID-19, as a human disease, has several identifying phases. Physicians of patients with COVID-19 may be interested in knowing whether opioid use disorder may affect their patients' course or prognosis. This information may be crucial when considering the opioid epidemic in the US and other parts of the world. Opioid use at high doses and over several months duration can mitigate the immune system's function, which may complicate the course of COVID-19 disease. Potential suppression of parts of the immune response may be important in prevention, clinical support, and therapeutic use of medications in various phases of the COVID-19. Specifically, opioid use disorders via an inhalation route may enhance the "late hyper-inflammatory phase" or result in end-organ damage. It is well established that opioids decrease ventilation as their effect on the medullary respiratory centers increases the risk of pneumonia. This increased risk has been associated with immune-suppressive opioids. The ultimate role of opioids in COVID-19 is not clear. This paper endorses the need for clinical studies to decipher the role and impact of chronic opioid use on viral diseases such as COVID-19.
• Nakhaee, S., Brent, J., Hoyte, C., Farrokhfall, K., Shirazi, F. M., Askari, M., & Mehrpour, O. (2020). The effect of tramadol on blood glucose concentrations: a systematic review. Expert review of clinical pharmacology, 13(5), 531-543. doi:10.1080/17512433.2020.1756773
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  : Studies comprehensively summarizing the impact of tramadol use on glucose homeostasis are very sparse. Thus, the present study was performed to collect and summarize the latest information about this issue in a systematic way.: An exhaustive literature search was carried out using relevant keywords. Web of Sciences, PubMed, Scopus, and Google scholar were interrogated until 30 June 2019. Case-control, cohort, cross-sectional, clinical trial, case report, and animal studies that focused on the objective of the study were retrieved. This review summarizes the results of 761 papers on glycemic changes due to tramadol exposure. Thirty-six publications reported hypoglycemia and 17 hyperglycemia during tramadol use. Twenty-two studies either reported normal blood glucose concentrations, or did not observe any difference in the blood glucose levels following tramadol use. Finally, hypoglycemia was reported in diabetic individuals exposed to tramadol in 12 studies.: The data suggest that primarily hypoglycemia but some degree of hyperglycemia has been reported with tramadol use. Importantly, all studies on tramadol use in diabetes reported hypoglycemia. Tramadol-induced hypoglycemia may be severe in some cases. The risk of alterations in glucose homeostasis accompanying tramadol exposure indicates time importance of careful blood glucose monitoring during tramadol use. Received 27 Nov 2019, Accepted 14 Apr 2020, Accepted author version posted online: 15 Apr 2020, Published online: 12 May 2020
• Rahimian, R., Mazda Shirazi, F., Schmidt, J. O., & Klotz, S. A. (2020). The Reply. The American Journal of Medicine, 133(6), e322.
• Shirazi, F. M., Banerji, S., Nakhaee, S., & Mehrpour, O. (2020). Effect of angiotensin II blockers on the prognosis of COVID-19: a toxicological view. European journal of clinical microbiology & infectious diseases : official publication of the European Society of Clinical Microbiology, 39(10), 2001-2002.
• Shirazi, F. M., Ryall, K. A., Reynolds, K. M., Lavonas, E. J., Delva-clark, H., & Dart, R. C. (2020). Continuous infusion as an alternative administration strategy of ovine Fab antivenom: initial experience in 41 cases. Toxicon, 182, S1-S2. doi:10.1016/j.toxicon.2020.04.009
• Shirazi, F. M., Shirazi, F. M., Schmidt, J. O., Rahimian, R., & Klotz, S. A. (2020). Honeybee Stings in the Era of Killer Bees: Anaphylaxis and Toxic Envenomation.. The American journal of medicine, 133(5), 621-626. doi:10.1016/j.amjmed.2019.10.028
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  Twenty-six years after the arrival of "killer bees" in Arizona, the entire state with the exception of high elevations in the north is populated with this bee variety and 11 people have died at the scene of massive bee attacks..Because of the aggressive behavior of these bees we studied bee stings reported to the Arizona Poison and Drug Information Center. The center received 399 calls regarding 312 victims of bee stings from January 2017 to June 2019. Calls originated from private residences and emergency centers..Stings occurred at victims' home residences in 272 (84.7%) of cases and 24 (7.5%) in public areas; 251 people suffered 1 sting; 42 individuals, 2-10 stings, 4 had 11-49 stings, and 13 individuals had >50 stings (so-called massive stinging). Three individuals were admitted to intensive care units (ICU) and one 35-year-old man died of anaphylaxis after 1 sting; moderate clinical effects occurred in 32 individuals including 6 admitted to the hospital but not in the intensive care unit. Anaphylaxis occurred in 30 (9.6%) of individuals, 16 receiving 1 sting. Toxic effects, tachycardia, elevated creatinine, or rhabdomyolysis occurred in 13 (4.2%) individuals..In the past, individuals stung more than 50 times were beekeepers working with European honeybees, whereas, in the current era, single as well as massive stings are the result of feral "killer bees." This change in epidemiology requires a new approach to sting victims: those with massive stinging should be evaluated and observed for anaphylaxis and serial laboratory values obtained for days to detect the toxic effects of envenomation.
• Smelski, G., Shirazi, F., Junak, M., & Brady, M. (2020). Rattlesnake Envenomation in the Setting of Disrupted Lymphatic Flow: A Case Series. Journal of Clinical Toxicology, 10(6), 1-4. doi:10.35248/2161-0495.20.10.455
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  Objective: Rattlesnake envenomation is a pathophysiologically complex process with a range of local effects including pain, erythema, local edema resembling compartment syndrome, ecchymosis that extends beyond the bitten extremity, as well as the development of blisters, bullae and tissue necrosis in severe cases. Previous animal studies have suggested that lymphatic flow is a crucial part of dissemination of venom after initial injection to produce systemic effects. However, the effects of baseline lymphatic obstruction on local injury in humans have yet to be described clinically. Methods: Three cases of patients that sustained rattlesnake bites with a history of lymphatic disruptions were reviewed, two with histories of mastectomies and one with chronic lower extremity lymphedema. All three patients experienced bites on the limb affected by lymphatic obstruction, yet their presentation of local symptoms and treatment regimens varied. Results: The first case describes a woman with a history of bilateral mastectomy and complete lymph node dissection who was bitten on her upper extremity and developed severe local cytotoxicity and tissue necrosis despite standard antivenom administration protocols. Providers in the second case treated the patient, who also had a history of mastectomy and complete lymph node dissection, more aggressively with repeat loading doses rather than maintenance dosing based on standard criteria of swelling progression greater than an inch an hour. In this instance, the patient had a favorable outcome with complete recovery of the local tissue and no evidence of necrosis. The final case, which involved a bite on an extremity with chronic lymphedema, resulted in delayed necrotic skin breakdown requiring two surgical debridements after initial standard antivenom dosing. Conclusion: The clinical outcomes of these cases revealed a more severe local injury with lymphatic disruption, suggesting that either venom is unable to travel systemically and concentrates at the site of injection or that antivenom therapy is unable to reach the site of the bite. Future studies are needed to better understand this relationship as this case series suggests that lymphatic obstruction may be a risk factor for more severe local injury.
• Yip, L., Bixler, D., Brooks, D. E., Clarke, K. R., Datta, S. D., Dudley, S., Komatsu, K. K., Lind, J. N., Mayette, A., Melgar, M., Pindyck, T., Schmit, K. M., Seifert, S. A., Shirazi, F. M., Smolinske, S. C., Warrick, B. J., & Chang, A. (2020). Serious Adverse Health Events, Including Death, Associated with Ingesting Alcohol-Based Hand Sanitizers Containing Methanol - Arizona and New Mexico, May-June 2020. MMWR. Morbidity and mortality weekly report, 69(32), 1070-1073.
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  Alcohol-based hand sanitizer is a liquid, gel, or foam that contains ethanol or isopropanol used to disinfect hands. Hand hygiene is an important component of the U.S. response to the emergence of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19). If soap and water are not readily available, CDC recommends the use of alcohol-based hand sanitizer products that contain at least 60% ethyl alcohol (ethanol) or 70% isopropyl alcohol (isopropanol) in community settings (1); in health care settings, CDC recommendations specify that alcohol-based hand sanitizer products should contain 60%-95% alcohol (≥60% ethanol or ≥70% isopropanol) (2). According to the Food and Drug Administration (FDA), which regulates alcohol-based hand sanitizers as an over-the-counter drug, methanol (methyl alcohol) is not an acceptable ingredient. Cases of ethanol toxicity following ingestion of alcohol-based hand sanitizer products have been reported in persons with alcohol use disorder (3,4). On June 30, 2020, CDC received notification from public health partners in Arizona and New Mexico of cases of methanol poisoning associated with ingestion of alcohol-based hand sanitizers. The case reports followed an FDA consumer alert issued on June 19, 2020, warning about specific hand sanitizers that contain methanol. Whereas early clinical effects of methanol and ethanol poisoning are similar (e.g., headache, blurred vision, nausea, vomiting, abdominal pain, loss of coordination, and decreased level of consciousness), persons with methanol poisoning might develop severe anion-gap metabolic acidosis, seizures, and blindness. If left untreated methanol poisoning can be fatal (5). Survivors of methanol poisoning might have permanent visual impairment, including complete vision loss; data suggest that vision loss results from the direct toxic effect of formate, a toxic anion metabolite of methanol, on the optic nerve (6). CDC and state partners established a case definition of alcohol-based hand sanitizer-associated methanol poisoning and reviewed 62 poison center call records from May 1 through June 30, 2020, to characterize reported cases. Medical records were reviewed to abstract details missing from poison center call records. During this period, 15 adult patients met the case definition, including persons who were American Indian/Alaska Native (AI/AN). All had ingested an alcohol-based hand sanitizer and were subsequently admitted to a hospital. Four patients died and three were discharged with vision impairment. Persons should never ingest alcohol-based hand sanitizer, avoid use of specific imported products found to contain methanol, and continue to monitor FDA guidance (7). Clinicians should maintain a high index of suspicion for methanol poisoning when evaluating adult or pediatric patients with reported swallowing of an alcohol-based hand sanitizer product or with symptoms, signs, and laboratory findings (e.g., elevated anion-gap metabolic acidosis) compatible with methanol poisoning. Treatment of methanol poisoning includes supportive care, correction of acidosis, administration of an alcohol dehydrogenase inhibitor (e.g., fomepizole), and frequently, hemodialysis.
• Panich, J., Gooden, A., Shirazi, F. M., & Malone, D. C. (2019). Warnings for drug-drug interactions in consumer medication information provided by community pharmacies. Journal of the American Pharmacists Association : JAPhA, 59(1), 35-42. doi:10.1016/j.japh.2018.09.008
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  In 2006, the U.S. Food and Drug Administration (FDA) issued a draft guidance for pharmacies to provide consumer medication information (CMI) to patients receiving prescription medications. The objective of this study was to evaluate CMI leaflets provided by community pharmacies for accuracy and completeness regarding drug-drug interactions (DDIs).
• August, J. A., Boesen, K. J., Hurst, N. B., Shirazi, F. M., & Klotz, S. A. (2018). Prophylactic Antibiotics Are Not Needed Following Rattlesnake Bites. The American Journal of medicine, 131(11), 1367-1371.
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  Antibiotics are sometimes administered to victims of rattlesnake bites in the hope of preventing infections. Experts in the field recommend that prophylactic antibiotics not be used because secondary infections are rare. Current recommendations are based on a small number of studies conducted in the United States. We decided to reexamine the issue by taking advantage of a large database on snakebites in Arizona. This allowed us to determine how often prophylactic antibiotics were used and whether or not they were effective.
• Barbuto, A. F., Roman, D. M., Ori, M., & Shirazi, F. M. (2018). Shock and lactic acidosis due to inadvertent intravenous albuterol. CLINICAL TOXICOLOGY, 56(10), 929-929.
• Holzman, S. D., Massey, D. J., Clements, A., Boesen, K. J., & Shirazi, F. M. (2018). Arizona Ridge-nosed rattlesnake envenomation: Case report of a personal encounter with the official state reptile of Arizona, Crotalus willardi willardi. Toxicon : official journal of the International Society on Toxinology, 151, 84-88. doi:10.1016/j.toxicon.2018.07.001
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  This case report describes the effects of an envenomation from one of the most infrequently encountered species of rattlesnake in the United States, Crotalus willardi willardi (C. w. willardi), the Arizona Ridge-nosed Rattlesnake. A previously healthy 57-year-old male sustained a bite to his non-dominant hand from a C. w. willardi. The most pronounced effect from the envenomation was edema and progression of edema that extended from his hand to the mid bicep. He also experienced erythema and tenderness to palpation in the affected limb, and some diminished range of motion in the hand. He expressed only minimal pain. Other than a mildly positive D-Dimer and leukocytosis, he had no significant hematologic effects and no systemic effects. He was treated with standard doses of Crotalidae Polyvalent Immune Fab (Ovine). He reported complete recovery from the envenomation within three days of the bite. Although envenomation from rattlesnakes is somewhat common in Arizona, knowing the exact species of snake is not. Confirmed documentation is exceedingly rare as most people do not recognize the different rattlesnake species. In addition, some species of rattlesnake (such as C. w. willardi) are especially reclusive and found only in isolated mountainous regions. Being able to confirm an envenomation by C. w. willardi would require not only someone knowledgeable in herpetology, but also, preferably, photographic evidence. This case has both.
• Hurst, N. B., Lipe, D. N., Karpen, S. R., Patanwala, A. E., Taylor, A. M., Boesen, K. J., & Shirazi, F. M. (2018). Centruroides sculpturatus envenomation in three adult patients requiring treatment with antivenom. Clinical toxicology (Philadelphia, Pa.), 56(4), 294-296. doi:10.1080/15563650.2017.1371310
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  Envenomation by Centruroides sculpturatus can manifest with cranial nerve dysfunction and neuromuscular hyperactivity. While these symptoms are most commonly seen in young children, they may also be seen in adults.
• Khobrani, M. A., Dudley, S. W., Huckleberry, Y. C., Kopp, B. J., Biggs, A. D., French, R., Shirazi, F. M., & Erstad, B. L. (2018). Intentional use of carbapenem antibiotics for valproic acid toxicity: A case report. JOURNAL OF CLINICAL PHARMACY AND THERAPEUTICS, 43(5), 723-725. doi:10.1111/jcpt.12705
• Ori, M. R., Larsen, J. B., & Shirazi, F. M. (2018). Mercury Poisoning in a Toddler from Home Contamination due to Skin- Lightening Cream. Journal Of Pediatrics, 196, 314-317.e 1. doi:10.1016/j.jpeds.2017.12.023
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  Nov 2018
• Rinner, G., Watkins, S. A., Curtis, K., Fernandez, M., & Shirazi, F. M. (2018). Massive fatal abrin poisoning by injection. CLINICAL TOXICOLOGY, 56(10), 998-998.
• Roman, D. M., Garrison, D. J., Larsen, J. B., French, R., & Shirazi, F. M. (2018). Successful ECMO for massive venlafaxine overdose. CLINICAL TOXICOLOGY, 56(10), 999-999.
• Shirazi, F. M., Roland, M., Schmid, K., Dudley, S., Kuhn, B., Rigler, J., Welch, S., Boesen, K. J., & Brooks, D. E. (2018). Poison centers respond to a state’s opioid crisis. Clinical Toxicology. doi:10.1080/15563650.2018.1506610
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  NAACT Abstracts 09/18
• Watkins, S. A., Boesen, K. J., & Shirazi, F. M. (2018). CRRT for metformin toxicity: is it enough?. CLINICAL TOXICOLOGY, 56(10), 1002-1003.
• Alharthi, M., Hurst, N., Boesen, K. J., & Shirazi, M. (2017). Venous thrombosis as a complication of rattlesnake envenomation. CLINICAL TOXICOLOGY, 55(7), 709-709.
• Malekzadeh, P., Hu, J., Sandweiss, A. J., Ameli, N., Bierny, P., Largent-Milnes, T. M., Vanderah, T. W., & Shirazi, F. (2017). Effect of Centruroides antivenom on reversal of methamphetamine-induced hyperkinesis and hyperthermia in rats. Journal of pharmaceutics & pharmacology, 5(1).
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  Methamphetamine (MA) toxicity is a major health concern causing agitation, hyperkinesia, hyperthermia, and even death, affecting 24.7 million people worldwide. It has been observed that MA generates movement disorders in children similar to that of scorpion envenomation. Four cases have been reported where MA intoxication in children were both subjectively and objectively improved as indicated by the reversal of nystagmus and movement disorders following administration of Centruroides antivenom (AV) therapy.
• Roman, D. M., Larsen, J. B., & Shirazi, F. M. (2017). Articles You Might Have Missed. Journal of Medical Toxicology, 13(3), 267-270. doi:10.1007/s13181-017-0620-x
• Shirazi, F. (2017). Case 26 - Rattlesnake Envenomation. American College of Emergency Physicians (ACEP) Toxicology Section.
• Klotz, S. A., Shirazi, F. M., Boesen, K., Beatty, N. L., Dorn, P. L., Smith, S., & Schmidt, J. O. (2016). Kissing Bug (Triatoma spp.) Intrusion into Homes: Troublesome Bites and Domiciliation. Environmental health insights, 10, 45-9. doi:10.4137/ehi.s32834
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  Kissing bugs (Triatoma spp.) frequently enter homes and bite human and pet occupants. Bites may lead to severe allergic reactions and, in some cases, death. Kissing bugs are also vectors of Trypanosoma cruzi, the cause of Chagas disease. In general, modern houses in the United States are not conducive to domiciliation of kissing bugs (bugs living out their entire life within the home with the presence of eggs, nymphs, adults, and exuviae). Construction features such as concrete foundations, solid walls and ceilings, window screens, tight thresholds for doors and windows, and other measures impede bug entry into homes, and air conditioning reduces the need for open doors and windows. Where Chagas disease is endemic in Mexico and Central and South America, homes often have thatch roofs, adobe walls, and open doors and windows. We investigated numerous instances of kissing bug intrusions into homes in Southern Arizona, California, and Louisiana and documented the reactions to kissing bug bites. Our work confirms the importance of modern home construction in limiting kissing bug intrusions. Older homes, especially those lacking modern screening, caulking, and weather stripping to reduce air leakage, may be subject to kissing bug intrusions and domiciliation. We describe a community in Southern Arizona where domiciliation of homes by Triatoma recurva is common. We also provide recent data regarding kissing bug bites and allergic reactions to the bites.
• Ori, M., Boesen, K. J., & Shirazi, F. M. (2016). Venom Dose Response in Genetically Related Multicasualty Massive Bee Envenomation. CLINICAL TOXICOLOGY, 54(8), 670-670.
• Rhodes, S. M., Patanwala, A. E., Cremer, J. K., Marshburn, E. S., Herman, M., Shirazi, F. M., Harrison-Monroe, P., Wendel, C., Fain, M., Mohler, J., & Sanders, A. B. (2016). Predictors of Prolonged Length of Stay and Adverse Events among Older Adults with Behavioral Health-Related Emergency Department Visits: A Systematic Medical Record Review. The Journal of Emergency Medicine, 50(1), 143-52.
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  Behavioral health (BH)-related visits to the emergency department (ED) by older adults are increasing. This population has unique challenges to providing quality, timely care.
• Bush, S. P., Ruha, A., Seifert, S. A., Morgan, D. L., Lewis, B. J., Arnold, T. C., Clark, R. F., Meggs, W. J., Toschlog, E. A., Borron, S. W., Figge, G. R., Sollee, D. R., Shirazi, F. M., Wolk, R., de Chazal, I., Quan, D., García-Ubbelohde, W., Alagón, A., Gerkin, R. D., & Boyer, L. V. (2015). Comparison of F(ab')2 versus Fab antivenom for pit viper envenomation: a prospective, blinded, multicenter, randomized clinical trial. Clinical toxicology (Philadelphia, Pa.), 53(1), 37-45.
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  Crotalidae Polyvalent Immune Fab (Ovine) has been the only antivenom commercially available in the US since 2007 for treatment of Crotalinae envenomation. Late coagulopathy can occur or recur after clearance of Fab antivenom, often after hospital discharge, lasting in some cases more than 2 weeks. There have been serious, even fatal, bleeding complications associated with recurrence phenomena. Frequent follow-up is required, and additional intervention or hospitalization is often necessary. F(ab')2 immunoglobulin derivatives have longer plasma half life than do Fab. We hypothesized that F(ab')2 antivenom would be superior to Fab in the prevention of late coagulopathy following treatment of patients with Crotalinae envenomation.
• Enakpene, E. O., Riaz, I. B., Shirazi, F. M., Raz, Y., & Indik, J. H. (2015). The long QT teaser: loperamide abuse. The American journal of medicine, 128(10), 1083-6.
• French, R., Brooks, D., Ruha, A., Shirazi, F., Chase, P., Boesen, K., & Walter, F. (2015). Gila monster (Heloderma suspectum) envenomation: Descriptive analysis of calls to United States Poison Centers with focus on Arizona cases. Clinical toxicology (Philadelphia, Pa.), 53(1), 60-70. doi:10.3109/15563650.2014.988791
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  The Gila monster (Heloderma suspectum) is a venomous lizard native to the deserts of southwestern United States (US) and northern Mexico. The purpose of this study was to describe human exposures to Gila monsters reported to US poison control centers (PCCs) with a focus on Arizona cases.
• Hurst, N., Karpen, S. R., Brillhart, D. B., French, R., Boesen, K. J., & Shirazi, F. (2015). Venous Thrombosis Following Rattlesnake Envenomation. Toxicon.
• Hypes, C. D., Hoverstadt, P., Lowry, J. S., Hurst, N., & Shirazi, F. (2015). Medical Image of the Week: Fluorescent Urine. Southwest Journal of Pulmonary and Critical Care, 11, 103-104.
• Strommen, J., & Shirazi, F. (2015). Methamphetamine Ingestion Misdiagnosed as Centruroides sculpturatus Envenomation. Case reports in emergency medicine, 2015, 1-3. doi:10.1155/2015/320574
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  The authors present a case report of a 17-month-old female child who ingested a large amount of methamphetamine that looked very similar clinically to a scorpion envenomation specific to the southwestern United States by the species Centruroides sculpturatus. The child was initially treated with 3 vials of antivenom specific for that scorpion species and showed a transient, though clinically relevant neurologic improvement. Her clinical course of sympathomimetic toxicity resumed and she was treated with intravenous fluids and benzodiazepines after blood analysis showed significant levels of d-methamphetamine. This case report is to specifically underline the clinical confusion in discerning between these two conditions and the realization of limited and/or expensive resources that may be used in the process.
• Walter, F. G., Stolz, U., French, R., Chase, P. B., McNally, J., & Shirazi, F. (2014). Epidemiology of the Reported Severity of Cottonmouth ( Agkistrodon piscivorus) Snakebite. SOUTHERN MEDICAL JOURNAL, 107(3), 150-156. doi:10.1097/SMJ.0000000000000067
• Alavala, A., Ulliman, E., Shirazi, M., & Szerlip, H. M. (2013). Quiz page October 2013: When things are not as they seem: a woman with anion gap metabolic acidosis after ingesting antifreeze. American journal of kidney diseases : the official journal of the National Kidney Foundation, 62(4), A25-8.
• Svirsky, I., Stoneking, L. R., Grall, K., Berkman, M., Stolz, U., & Shirazi, F. (2013). RESIDENT-INITIATED ADVANCED TRIAGE EFFECT ON EMERGENCY DEPARTMENT PATIENT FLOW. JOURNAL OF EMERGENCY MEDICINE, 45(5), 746-751. doi:10.1016/j.jemermed.2013.03.019
• Ennis, J. J., & Shirazi, F. (2012). Juvenile Rattlesnake Fang as a Retained Foreign Body: Clinical Diagnosis. Toxicon, 60(2), 219-220. doi:10.1016/j.toxicon.2012.04.242
• Kernan, L., Ito, S., Shirazi, F., & Boesen, K. (2012). Fatal gastrointestinal hemorrhage after a single dose of dabigatran. Clinical toxicology (Philadelphia, Pa.), 50(7), 571-3.
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  Dabigatran (Pradaxa) is a new oral anticoagulant approved by the Food and Drug Administration (FDA), available internationally and indicated as an alternative to warfarin for the prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation. Dabigatran does not require laboratory monitoring and its kinetics allow for a more rapid onset of action with a time to peak concentration of 1.25-1.5 h. We are reporting a fatality resulting from gastrointestinal bleeding after the ingestion of a single dose of dabigatran 150 mg.
• Walter, F. G., Stolz, U., Shirazi, F., Walter, C. M., & McNally, J. (2012). Epidemiology of the Reported Severity of Copperhead (Agkistrodon contortrix) Snakebite. SOUTHERN MEDICAL JOURNAL, 105(6), 313-320. doi:10.1097/SMJ.0b013e318257c2d5
• Daniel, G. W., Ewen, E., Willey, V. J., Reese, C. L., Shirazi, F., & Malone, D. C. (2010). Efficiency and Economic Benefits of a Payer-based Electronic Health Record in an Emergency Department. ACADEMIC EMERGENCY MEDICINE, 17(8), 824-833.
• Walter, F. G., Stolz, U., Shirazi, F., & Mcnally, J. (2010). Temporal analyses of coral snakebite severity published in the American Association of Poison Control Centers' Annual Reports from 1983 through 2007. CLINICAL TOXICOLOGY, 48(1), 72-78. doi:10.3109/15563650903430944
• Walter, F. G., Stolz, U., Shirazi, F., & McNally, J. (2009). Epidemiology of severe and fatal rattlesnake bites published in the American Association of Poison Control Centers' Annual Reports. CLINICAL TOXICOLOGY, 47(7), 663-669. doi:10.1080/15563650903113701
• Madadi, P., Shirazi, F., Walter, F. G., & Koren, G. (2008). Establishing causality of CNS depression in breastfed infants following maternal codeine use. Paediatric drugs, 10(6), 399-404.
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  We recently reported on a breastfed infant who succumbed to opioid toxicity following exposure to morphine, the active metabolite of codeine, which was prescribed to his mother who was a cytochrome P450 2D6 (CYP2D6) ultrarapid metabolizer. This report is believed to be the first case of neonatal fatality as a direct result of maternal drug excretion into breast milk and, therefore, it is critical to corroborate the causative relationship between maternal codeine use during breastfeeding and neonatal opioid toxicity with other existing evidence.
• Walter, F. G., Chan, J. T., Winegard, B., Chase, P. B., Shirazi, F., Chow, Y., de Boer, M., & Denninghoff, K. (2008). Hazmat disaster preparedness in Hong Kong: what are the hazardous materials on Lantau, Lamma, and Hong Kong Islands?. American journal of disaster medicine, 3(4), 213-33.
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  Hazmat disaster preparedness is critical, especially as Hong Kong prepares for major international events, such as the 2008 Olympic Equestrian Games. No published medical study describes the identities and quantities of hazardous materials (HMs) in Hong Kong and lists what antidotes are needed for these dangerous goods (DGs). This study describes what HMs are most common in Hong Kong to prioritize disaster preparedness and training.
• Walter, F. G., Chan, J., Winegard, B., Shirazi, F. M., Chase, P. B., Chow, Y. Y., de, B. M., & Denninghoff, K. (2008). Hazmat emergency preparedness in Hong Kong: what are the dangerous goods in Kowloon?. HONG KONG JOURNAL OF EMERGENCY MEDICINE, 15(3), 156-176.
• Coon, T., Miller, M., Shirazi, F., & Sullivan, J. (2006). Lead toxicity in a 14-year-old female with retained bullet fragments. PEDIATRICS, 117(1), 227-230.
• Skrepnek, G. H., Abarca, J., Malone, D. C., Armstrong, E. P., Shirazi, F. M., & Woosley, R. L. (2005). Incremental effects of concurrent pharmacotherapeutic regimens for heart failure on hospitalizations and costs. The Annals of pharmacotherapy, 39(11), 1785-91.
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  Inappropriate medication use in patients with heart failure (HF) presents challenges in providing optimal, evidence-based care.
• Velez, L., Shirazi, F., Goto, C., Shepherd, G., & Roth, B. A. (2003). Opisthotonic posturing with neuromuscular irritability attributable to 4-aminopyridine ingestion by a healthy pediatric patient. PEDIATRICS, 111(1).
• Towe, B., Shirazi, F., & Kakavand, A. (1996). Investigation of cancer tumor biopotential in relation to tumor pH. Electro- and Magnetobiology, 15(1). doi:10.3109/15368379609016162
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  Biopotentials associated with adenocarcinomas in mice and hamsters were measured using a tumor-penetrating microelectrode system. Tumor ionic compositions and pH were determined by microsampling and by pH microelectrodes. We observed that the pH gradient through the tumor mass approximately follows the tumor biopotential gradient. We show that the magnitude of the observed tumor biopotentials can be explained in terms of Nernst-Planck diffusion potentials arising from tumor pH gradients.
• LLOYD, T. R., & SHIRAZI, F. (1990). CAMP-MEDIATED CARDIOMYOCYTE HYPERTROPHY REQUIRES EXCITATION-CONTRACTION COUPLING. AMERICAN JOURNAL OF CARDIOLOGY, 66(4), 527-527.
• LLOYD, T. R., & SHIRAZI, F. (1990). NONGEOMETRIC DOPPLER STROKE VOLUME DETERMINATION IS LIMITED BY AORTIC SIZE. AMERICAN JOURNAL OF CARDIOLOGY, 66(10), 883-884. doi:org/10.1016/002-914(90)90377-D.
• LLOYD, T. R., DONNERSTEIN, R. L., & SHIRAZI, F. (1990). OBSTRUCTION OF SYSTEMIC PULMONARY ARTERIAL SHUNTS BY DIAGNOSTIC CARDIAC CATHETERS. AMERICAN JOURNAL OF CARDIOLOGY, 66(10), 878-880. doi:org/10.1016/0002-9149(90)90375-B

Proceedings Publications

• Bosen, K., Shirazi, F., & Larsen, J. (2017, January). Characterization of poison center calls from critical access hospitals in rural Arizona. In North American Congress of Clinical Toxicology (NACCT) Clinical Toxicology, 55, 823-824.
• Shirazi, F. (2017, January). Rattlesnake envenomation in a patient with Erhlers-Danlos Syndrome. In North American Congress of Clinical Toxicology (NACCT) Clinical Toxicology, 55, 733.

Presentations

• Shirazi, F., & Klotz, S. (2022, Sept/Fall). Poisoning from Liquid Social Lubricants other than Ethanol. Arizona Telemedicine Program. Webinar: Health Resources and Services Administration, Office for the Advancement of Telehealth.
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  Arizonans kill themselves accidentally every year with these liquids thinking they are alcohol. Discusion on understanding the pathophysiology and recognizing the signs of this dangerous combination. Information will be shared on the risks for harm and preventative steps healthcare professionals can take in caring for patients experiencing this type of poisoning. The topics for this webinar are:1. Learn how to recognize methanol and isopropyl alcohol poisoning, how and where         they happen.2. Learn the pathophysiology of these two poisons.3. Learn about therapy of these poisonings.4. Learn the risks for harm with these poisons and preventative steps that can be taken.
• Shirazi, F., Klotz, S., Dudley, S., & Morehouse, L. (2022, Feb/Spring). Arizona Poison & Drug Information Center Stepped up during COVID for Arizonans. Arizona Telemedicine Program. Webinar: Health Resources and Services Administration, Office for the Advancement of Telehealth.
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  A significant challenge of the COVID-19 epidemic was the dissemination of accurate and timely information to the public, health care providers, and first responders. The Arizona Poison and Drug Information Center (APDIC), housed in the UArizona College of Pharmacy, took on this challenge andexpanded significantly to fill this need. Learn from these UArizona experts how they stepped up to respond to the public health need!The topics for this webinar are:1. How Center transforms itself to become informational source on COVID-19 for state of Arizona2. COVID-19 issues that were addressed and tracked3. Results and lessons learned
• Shirazi, F., & Klotz, S. (2021, Apr/Spring). Virtual Office Hours. Arizona Telemedicine Program. Webinar: Arizona Telemedicine Program.
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  An open discussion on "Poison Centers and COVID Information: Disease, Drugs and Vaccines."
• Shirazi, F., Klotz, S., & Schnidt, J. (2021, June/Summer). Scorpion Stings: Important things healthcare workers should know!. Arizona Telemedicine Program. Webinar: Health Resources and Services Administration, Office for the Advancement of Telehealth.
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  The objectives for this webinar are:1. Discuss the epidemiology of scorpion stings in Arizona2. Discuss the biology of scorpions 3. Discuss the treatment of scorpion stings.
• Rice, A., Gaither, J. B., French, R. N., Beskind, D. L., Smith, J., Shirazi, F., & Walter, F. G. (2020, January). EMS Medical Directors Advanced Hazmat Life Support for Tox-Medics. National Association of EMS Physicians (NAEMSP) 2020 Annual Meeting. San Diego, CA: NAEMSP.
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  Full day pre-conference workshop presentation
• Ainapurapu, B. B., Shirazi, F., & Swazo, R. (2019, May). Confused and Belligerent Professor. Medicine Grand Rounds/CPC. UACOM.

Poster Presentations

• Elias-Campa, D., Edwards, C. J., Hurst, N. B., Shirazi, F., & Ng, V. (2024, December).

  Identifying preventable and anon-preventable prescription clarification callbacks at an academic medical center from 2015-2024

  . ASHP's Midyear Clinical Meeting. New Orleans: ASHP.
• Thiss, T., Maciulewicz, T., Larsen, J., & Shirazi, F. (2023, Mar. 31 - Apr. 2). Massive Isolated Topiramate Ingestion with Marked Improvement after Hemodialysis. ACMT Annual Scientific Meeting. San Diego, CA: American Academy of Medical Toxicology (ACMT).
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  poster presentation and published abstract
• Adhikari, S. R., Acuna, J., Situ-LaCasse, E., & Shirazi, F. (2020, October/Fall). Point-of-care Ultrasound in the Evaluation of Rattlesnake Envenomation. ACEP Research forum.
• Hurst, N., Reilly, J. N., Boesen, K. J., & Shirazi, F. (2017, May). Epidemiology of rattlesnake envenoming reported to an Arizona Poison Center. 37th International Congress of the European Association of Poisons Centres and Clinical Toxicologists (EAPCCT). Basel, Switzerland: European Association of Poisons Centres and Clinical Toxicologists (EAPCCT).

Others

• Hurst, N. B., Boesen, K. J., & Shirazi, F. M. (2015, September). Venous Thrombosis Following Rattlesnake Envenomation. The 18th World Congress of the International Society of Toxicology.
• Hurst, N. B., Karpen, S. R., French, R. N., Boesen, K. J., & Shirazi, F. M. (2015, AUG). ST elevation myocardial infarction following envenomation by North American Crotalus species. CLINICAL TOXICOLOGY.
• Hurst, N. B., Karpen, S. R., Myrtle, C., French, R. N., Boesen, K. J., & Shirazi, F. M. (2015, AUG). Prolonged recurrent coagulopathy after North American crotalus envenomation. CLINICAL TOXICOLOGY.
• Karpen, S. R., Hurst, N. B., Plitt, J., Chase, P., & Shirazi, F. M. (2015, AUG). Congenital lead poisoning in three siblings from a mother with retained bullet fragments. CLINICAL TOXICOLOGY.
• Karpen, S., Hurst, N. B., Lipe, D. N., Patanwala, A., Boesen, K. J., & Shirazi, F. M. (2015, AUG). Centuroides sculpturatus envenomation in three adult patients requiring treatment with antivenom. CLINICAL TOXICOLOGY.