1
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Levitas M, Thomas C, Widman C, DeColumna J, Allgaier B, Conley E, deHagen T, Freitas I, Horvath H, Lemberg B, Lemberg D. Qualitative and quantitative determination of xylazine in oral fluid. J Anal Toxicol 2024:bkae055. [PMID: 39002106 DOI: 10.1093/jat/bkae055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 06/12/2024] [Accepted: 06/18/2024] [Indexed: 07/15/2024] Open
Abstract
Xylazine has emerged in recent years as a dangerous adulterant in illicit fentanyl use, and methods for the detection of xylazine in toxicology panels are still lagging. We developed methods for the screening and quantitation of xylazine in oral fluid (OF), a popular testing medium due to its ease of collection and reflection of presence in blood for many classes of drugs. Enzyme-linked immunosorbent assays were employed for the rapid screening of xylazine directly from the collection device buffer with a cutoff of 1 ng/mL. Solid-phase extraction coupled with liquid chromatography-tandem mass spectrometry facilitated the confirmation and quantification of xylazine as low as 0.1 ng/mL and a dynamic range of 0.1-25 ng/mL. Selectivity, ionization suppression, processed sample stability, and dilution effect were also assessed. The method was validated through the American National Standards Institute/American Academy of Forensic Sciences Standards Board (ANSI/ASB) Standard 036, first edition from 2019, and found to be accurate, precise, and robust. Living human subject OF samples collected within substance use disorder and therapeutic drug monitoring clinics received between September 2023 and January 2024, with the specific request to test for xylazine (n = 57), were screened. Presumptive positive samples were confirmed using the validated method. Xylazine confirmed living human subject OF sample concentrations ranged from 1.2 to 23.3 ng/mL.
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Affiliation(s)
- Matthew Levitas
- Forensic Fluids Laboratories, 225 Parsons Street, Kalamazoo, MI 49007, USA
| | - Christopher Thomas
- Forensic Fluids Laboratories, 225 Parsons Street, Kalamazoo, MI 49007, USA
| | - Corey Widman
- Forensic Fluids Laboratories, 225 Parsons Street, Kalamazoo, MI 49007, USA
| | - Joseph DeColumna
- Forensic Fluids Laboratories, 225 Parsons Street, Kalamazoo, MI 49007, USA
| | - Brandi Allgaier
- Forensic Fluids Laboratories, 225 Parsons Street, Kalamazoo, MI 49007, USA
| | - Eric Conley
- Forensic Fluids Laboratories, 225 Parsons Street, Kalamazoo, MI 49007, USA
| | - Troy deHagen
- Forensic Fluids Laboratories, 225 Parsons Street, Kalamazoo, MI 49007, USA
| | - Isabela Freitas
- Forensic Fluids Laboratories, 225 Parsons Street, Kalamazoo, MI 49007, USA
| | - Hannah Horvath
- Forensic Fluids Laboratories, 225 Parsons Street, Kalamazoo, MI 49007, USA
| | - Bridget Lemberg
- Forensic Fluids Laboratories, 225 Parsons Street, Kalamazoo, MI 49007, USA
| | - Dave Lemberg
- Forensic Fluids Laboratories, 225 Parsons Street, Kalamazoo, MI 49007, USA
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2
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Warp PV, Hauschild M, Serota DP, Ciraldo K, Cruz I, Bartholomew TS, Tookes HE. A confirmed case of xylazine-induced skin ulcers in a person who injects drugs in Miami, Florida, USA. Harm Reduct J 2024; 21:64. [PMID: 38491467 PMCID: PMC10941577 DOI: 10.1186/s12954-024-00978-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 03/01/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND Xylazine is an alpha-2 adrenergic receptor agonist that has emerged as a contaminant in the illicit drug supply of fentanyl. Xylazine use may be suspected in naloxone-resistant overdoses and atypical, chronic wounds in people who use drugs (PWUD). This case is unique because it is the first case to our knowledge describing wound care for a xylazine-induced wound with a confirmatory xylazine test strip (XTS) in the setting of a syringe services program (SSP) and in the state of Florida. CASE PRESENTATION A 43-year-old woman with a past medical history of severe opioid use disorder and stimulant use disorder presented to a student-run clinic at a Miami SSP for wound care. She had multiple ulcerations diffusely over her bilateral forearms with surrounding erythema and warmth. Seven weeks later, she presented to clinic again for wound care because her wounds had progressed. At this visit, a XTS was used to confirm the presence of xylazine in her urine. Wound care management and harm reduction strategies employed at both visits were informed by best clinical judgement due to lack of formal guidelines at the time. Wound outcomes are unknown as the patient has not returned to clinic. CONCLUSIONS Many PWUD at highest risk for acute and chronic health consequences of xylazine-adulterated fentanyl do not have access to healthcare outside of low barrier clinics and SSPs due to lack of insurance or mistrust of the traditional healthcare system due to stigma. There is an urgent need for access to XTS for PWUD and clinical practice guidelines for the treatment of xylazine-related wounds in outpatient clinics.
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Affiliation(s)
- Peyton V Warp
- Department of Medical Education, University of Miami Miller School of Medicine, 1600 NW 10th Ave, Suite 1149, Miami, FL, 33136, USA.
| | - Maia Hauschild
- Department of Medical Education, University of Miami Miller School of Medicine, 1600 NW 10th Ave, Suite 1149, Miami, FL, 33136, USA
| | - David P Serota
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Katrina Ciraldo
- Department of Family Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Irasema Cruz
- IDEA Exchange, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Tyler S Bartholomew
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Hansel E Tookes
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
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3
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Mai T, Zhang Y, Zhao S. Xylazine Poisoning in Clinical and Forensic Practice: Analysis Method, Characteristics, Mechanism and Future Challenges. TOXICS 2023; 11:1012. [PMID: 38133413 PMCID: PMC10748319 DOI: 10.3390/toxics11121012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 12/07/2023] [Accepted: 12/09/2023] [Indexed: 12/23/2023]
Abstract
Xylazine abuse is emerging globally, while the identification of xylazine lethal cases poses a great challenge in clinical and forensic practice. The non-specific symptoms delay the diagnosis and treatment of xylazine poisoning, the pathological changes and lethal concentration of xylazine in body fluid and organs of fatal xylazine poisoning cases are seldom reported and the other toxins detected in such cases complicate the role of xylazine in the cause of death. Therefore, we carefully reviewed related updated information on xylazine, summarized the knowledge from clinical and forensic perspectives and can thus provide a reference in such cases and throw light on further study in the field of xylazine poisoning.
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Affiliation(s)
- Tingting Mai
- Faculty of Forensic Medicine, Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou 510275, China;
- Guangdong Province Translational Forensic Medicine Engineering Technology Research Center, Guangzhou 510275, China
| | - Youyou Zhang
- Department of Geriatric Neurology, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710004, China;
| | - Shuquan Zhao
- Faculty of Forensic Medicine, Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou 510275, China;
- Guangdong Province Translational Forensic Medicine Engineering Technology Research Center, Guangzhou 510275, China
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4
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Hoffman RS. Closing the xylazine knowledge gap. Clin Toxicol (Phila) 2023; 61:1013-1016. [PMID: 38270058 DOI: 10.1080/15563650.2023.2294619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Affiliation(s)
- Robert S Hoffman
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY, USA
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5
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Warp PV, Hauschild M, Tookes HE, Ciraldo K, Serota DP, Cruz I. A Confirmed Case of Xylazine-Induced Skin Ulcers in a Person Who Injects Drugs in Miami, Florida, USA. RESEARCH SQUARE 2023:rs.3.rs-3194876. [PMID: 37547000 PMCID: PMC10402246 DOI: 10.21203/rs.3.rs-3194876/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
Background Xylazine is an alpha-2 adrenergic receptor agonist that has emerged as a contaminant in the street drug supply of fentanyl. Xylazine use may be suspected in naloxone-resistant overdoses and atypical, chronic wounds in people who inject drugs (PWID). This case is unique because it is the first case to our knowledge describing wound care for a xylazine-induced wound with a confirmatory xylazine test strip (XTS) in the setting of a syringe services program (SSP) and in the state of Florida. Case Presentation A 43-year-old woman with a past medical history of severe opioid use disorder and stimulant use disorder presented to a student-run clinic at the IDEA Miami SSP for wound care. She had multiple ulcerations diffusely over her bilateral forearms with surrounding erythema and warmth. Seven weeks later, she presented to clinic again for wound care because her wounds had progressed. At this visit, a XTS was used to confirm the presence of xylazine in her urine. Wound care management and harm reduction strategies employed at both visits are discussed below. Wound outcomes are unknown as the patient has not returned to clinic. Conclusions Many PWID at highest risk for acute and chronic health consequences of xylazine-adulterated fentanyl do not have access to healthcare outside of low barrier clinics and SSPs due to lack of insurance or mistrust of the traditional healthcare system. There is an urgent need for access to XTS for PWID and clinical practice guidelines for the treatment of xylazine-related wounds in outpatient clinics.
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Affiliation(s)
| | | | - Hansel E Tookes
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine
| | - Katrina Ciraldo
- Department of Family Medicine, University of Miami Miller School of Medicine
| | - David P Serota
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine
| | - Irasema Cruz
- IDEA Exchange, University of Miami Miller School of Medicine
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Ayub S, Parnia S, Poddar K, Bachu AK, Sullivan A, Khan AM, Ahmed S, Jain L. Xylazine in the Opioid Epidemic: A Systematic Review of Case Reports and Clinical Implications. Cureus 2023; 15:e36864. [PMID: 37009344 PMCID: PMC10063250 DOI: 10.7759/cureus.36864] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2023] [Indexed: 03/30/2023] Open
Abstract
INTRODUCTION AND OBJECTIVES The opioid overdose epidemic is exacerbated by the emergence of Xylazine as an illicit drug adulterant. Xylazine, a veterinary sedative, can potentiate opioid effects while also causing toxic and potentially fatal side effects. This systematic review aims to assess the impact of Xylazine use and overdoses within the opioid epidemic context. METHOD A systematic search was conducted following PRISMA guidelines to identify relevant case reports, and case series related to Xylazine use. A comprehensive literature search included databases like Web of Science, PubMed, Embase, and Google Scholar, utilizing keywords and Medical Subject Headings (MeSH) terms related to Xylazine. Thirty-four articles met the inclusion criteria for this review. RESULTS Intravenous (IV) administration was a common route for Xylazine use among various methods, including subcutaneous (SC), intramuscular (IM), and inhalation, with overall doses ranging from 40 mg to 4300 mg. The average dose in fatal cases was 1,200 mg, compared to 525 mg in non-fatal cases. Concurrent administration of other drugs, primarily opioids, occurred in 28 cases (47.5%). Intoxication was identified as a notable concern in 32 out of 34 studies, and treatments varied, with the majority experiencing positive outcomes. Withdrawal symptoms were documented in one case study, but the low number of cases with withdrawal symptoms may be attributed to factors such as a limited number of cases or individual variation. Naloxone was administered in eight cases (13.6%), and all patients recovered, although it should not be misconstrued as an antidote for Xylazine intoxication. Of the 59 cases, 21 (35.6%) resulted in fatal outcomes, with 17 involving Xylazine use in conjunction with other drugs. The IV route was a common factor in six out of the 21 fatal cases (28.6%). CONCLUSION This review highlights the clinical challenges associated with Xylazine use and its co-administration with other substances, particularly opioids. Intoxication was identified as a major concern, and treatments varied across the studies, including supportive care, naloxone, and other medications. Further research is needed to explore the epidemiology and clinical implications of Xylazine use. Understanding the motivations and circumstances leading to Xylazine use, as well as its effects on users, is essential for developing effective psychosocial support and treatment interventions to address this public health crisis.
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7
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Deutsch SA, De Jong AR. Xylazine Complicating Opioid Ingestions in Young Children. Pediatrics 2023; 151:190352. [PMID: 36550066 DOI: 10.1542/peds.2022-058684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/05/2022] [Indexed: 12/24/2022] Open
Abstract
The authors of this report present 3 cases of synthetic opioid intoxication complicated by the concomitant presence of the additive xylazine, a nonopioid sedative analgesic and muscle relaxant used in veterinary medicine that potentiates respiratory depression associated with the opioid toxidrome. Three exposed children presented with severe signs and symptoms, 2 of whom experienced cardiac arrest, a need for continuous naloxone infusion or multiple naloxone doses, or mechanical ventilation to treat respiratory failure after their exposures. Additives were detected in urine studies only through the performance of specialized toxicology testing. Detection of xylazine among adult overdose deaths has recently increased sharply, particularly across the northeastern United States. Adulteration by xylazine is an emerging public health threat nationally. Our report reveals that pediatricians should be aware of sentinel drug trends among adults, including the emerging types of illicit, synthetic, or counterfeit formulations of recreational substances, because children may be harmed because of accidental or intentional exposure. Children exposed to dangerous substances also need child protection services that may entail safe relocation outside of the home and the referral of affected caregivers to necessary substance use treatment services. Given epidemic drug use among adults, pediatricians should be competent to recognize common toxidromes and be aware that signs and symptoms may be potentiated by synergistic novel additives or polysubstance exposures. Importantly, standard urine drug screens may not detect synthetic opioid derivatives or contributing additives, so that diagnosis will require specialized toxicology testing.
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8
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Zhang Z, Bai H, Zhang B, Shen M, Gao L. Comparison of cardiorespiratory and anesthetic effects of ketamine-midazolam-xylazine-sufentanil and tiletamine-zolazepam-xylazine in miniature pigs. PLoS One 2022; 17:e0271325. [PMID: 35819978 PMCID: PMC9275679 DOI: 10.1371/journal.pone.0271325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 06/28/2022] [Indexed: 11/29/2022] Open
Abstract
Effective and adequate anesthesia is conducive to better restrain for pigs during surgical or diagnostic procedures This study aimed to evaluate cardiorespiratory and anesthetic effects of ketamine-midazolam-xylazine-sufentanil or tiletamine-zolazepam-xylazine as general anesthetics in miniature pigs. In phase 1, one of the combinations was administered intramuscularly to miniature pigs. The KMXS protocol combined 10 mg kg-1 ketamine, 0.5 mg kg-1 midazolam, and 2 mg kg-1 xylazine with 2 μg kg-1 sufentanil. The TZX protocol combined 2.2 mg kg-1 tiletamine, 2.2 mg kg-1 zolazepam, and 1.4 mg kg-1 xylazine. After treatment, the mean arterial pressure, systolic arterial pressure, diastolic arterial pressure, heart rate, respiratory rate, peripheral hemoglobin oxygen saturation, rectal temperature, and anesthesia quality were recorded. In phase 2, the feasibility of KMXS and TZX as general anesthetics were evaluated for pig castration. In phase 1, both drug combinations provided smooth induction with similar anesthetic effects. The KMXS protocol provided moderate anesthesia for 60–70 minutes in pigs, while the TZX protocol provided 30–45 minutes. In phase 2, castration was completed smoothly in all pigs with little fluctuation in physiological variables. The KMXS protocol is better for medium-term anesthesia, while the TZX protocol is preferable for short-term anesthesia in pigs.
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Affiliation(s)
- Zhiheng Zhang
- College of Veterinary Medicine, Northeast Agricultural University, Harbin, Heilongjiang, China
| | - Hui Bai
- College of Veterinary Medicine, Northeast Agricultural University, Harbin, Heilongjiang, China
| | - Bo Zhang
- College of Veterinary Medicine, Northeast Agricultural University, Harbin, Heilongjiang, China
| | - Meilun Shen
- College of Veterinary Medicine, Northeast Agricultural University, Harbin, Heilongjiang, China
| | - Li Gao
- College of Veterinary Medicine, Northeast Agricultural University, Harbin, Heilongjiang, China
- Heilongjiang Key Laboratory for Laboratory Animals and Comparative Medicine, College of Veterinary Medicine, Northeast Agriculture University, Harbin, China
- * E-mail:
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9
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Kacinko SK, Mohr ALA, Logan BK, Barbieri EJ. Xylazine: Pharmacology Review and Prevalence and Drug Combinations in Forensic Toxicology Casework. J Anal Toxicol 2022; 46:911-917. [PMID: 35770859 DOI: 10.1093/jat/bkac049] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 06/13/2022] [Accepted: 06/29/2022] [Indexed: 11/14/2022] Open
Abstract
Xylazine, an alpha-2 receptor agonist used in veterinary medicine for its sedative and muscle relaxant effects, has been reported in forensic toxicology casework since the 1980s. It is not approved for human use, but it is used as an adulterant in heroin and illicit fentanyl. The prevalence and concentrations of xylazine in 2.5 years (January 2019-June 2021) of driving-under-the-influence-of-drugs (DUID) and medical-death-investigation (MDI) cases was investigated, including other drugs detected in combination with xylazine. Of over 170,000 cases screened for xylazine, 97% were classified as MDI. Over the course of the study period the prevalence and geographical spread of xylazine increased. Overall, 2.8% of DUID and 2.1% of MDI cases screened positive for xylazine with concentrations of 5.1-450 ng/mL (mean = 36 ng/mL) and 5.0-11,000 ng/mL (mean = 41 ng/mL), respectively. Two MDI cases which had xylazine concentrations of 9,100 and 11,000 ng/mL were drug overdose suicides that did not involve any opioids. Opioids, primarily fentanyl and/or a fentanyl byproduct/metabolite were detected in 100% of DUID and all but two MDI cases. After opioids, stimulants, phyto-cannabinoids and benzodiazepines were the most common drug classes detected in conjunction with xylazine in both DUID and MDI casework. In summary, xylazine exposure continues to increase, mostthrough the adulteration of illicit opioids. There is extensive overlap in the concentrations between living and deceased individuals making it difficult to interpret the role of the drug in MDI or DUID cases without other case information.
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Affiliation(s)
- S K Kacinko
- NMS Labs, 200 Welsh Rd, Horsham, PA 19044, USA
| | - A L A Mohr
- Center for Forensic Science Research and Education at the Fredric Rieders Family Foundation, 2300 Stratford Ave, Willow Grove, PA 19090, USA
| | - B K Logan
- NMS Labs, 200 Welsh Rd, Horsham, PA 19044, USA.,Center for Forensic Science Research and Education at the Fredric Rieders Family Foundation, 2300 Stratford Ave, Willow Grove, PA 19090, USA
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Saisahas K, Soleh A, Promsuwan K, Saichanapan J, Phonchai A, Sadiq NS, Teoh WK, Chang KH, Abdullah AFL, Limbut W. Nanocoral-like Polyaniline-Modified Graphene-Based Electrochemical Paper-Based Analytical Device for a Portable Electrochemical Sensor for Xylazine Detection. ACS OMEGA 2022; 7:13913-13924. [PMID: 35559175 PMCID: PMC9088932 DOI: 10.1021/acsomega.2c00295] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 03/29/2022] [Indexed: 06/15/2023]
Abstract
A portable electrochemical device for xylazine detection is presented for the first time. An electrochemical paper-based analytical device (ePAD) was integrated with a smartphone. The fabrication of the ePAD involved wax printing, low-tack transfer tape, and cutting and screen-printing techniques. Graphene ink was coated on the substrate and modified with nanocoral-like polyaniline, providing an electron transfer medium with a larger effective surface area that promoted charge transfer. The conductive ink on the ePAD presented a thickness of 25.0 ± 0.9 μm for an effective surface area of 0.374 cm2. This sensor was then tested directly on xylazine using differential pulse voltammetry. Two linear responses were obtained: from 0.2 to 5 μg mL-1 and from 5 to 100 μg mL-1. The detection limit was 0.06 μg mL-1. Reproducibility was tested on 10 preparations. The relative standard deviation was less than 5%. The applicability of the sensor was evaluated with beverage samples spiked with trace xylazine. Recoveries ranged from 84 ± 4 to 105 ± 2%. The developed sensor demonstrated excellent accuracy in the detection of trace xylazine. It would be possible to develop the portable system to detect various illicit drugs to aid forensic investigations.
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Affiliation(s)
- Kasrin Saisahas
- Forensic
Science Programme, School of Health Sciences, Universiti Sains Malaysia, Kubang
Kerian, Kelantan 16150, Malaysia
| | - Asamee Soleh
- Center
of Excellence for Trace Analysis and Biosensors (TAB-CoE), Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
- Center
of Excellence for Innovation in Chemistry, Faculty of Science, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
- Division
of Physical Science, Faculty of Science, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
| | - Kiattisak Promsuwan
- Center
of Excellence for Trace Analysis and Biosensors (TAB-CoE), Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
- Division
of Health and Applied Sciences, Faculty of Science, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
- Forensic
Science Innovation and Service Center, Prince
of Songkla University, Hat Yai, Songkhla 90110, Thailand
| | - Jenjira Saichanapan
- Division
of Health and Applied Sciences, Faculty of Science, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
- Forensic
Science Innovation and Service Center, Prince
of Songkla University, Hat Yai, Songkhla 90110, Thailand
| | - Apichai Phonchai
- Division
of Health and Applied Sciences, Faculty of Science, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
- Forensic
Science Innovation and Service Center, Prince
of Songkla University, Hat Yai, Songkhla 90110, Thailand
| | | | - Way Koon Teoh
- Forensic
Science Programme, School of Health Sciences, Universiti Sains Malaysia, Kubang
Kerian, Kelantan 16150, Malaysia
| | - Kah Haw Chang
- Forensic
Science Programme, School of Health Sciences, Universiti Sains Malaysia, Kubang
Kerian, Kelantan 16150, Malaysia
| | - Ahmad Fahmi Lim Abdullah
- Forensic
Science Programme, School of Health Sciences, Universiti Sains Malaysia, Kubang
Kerian, Kelantan 16150, Malaysia
| | - Warakorn Limbut
- Center
of Excellence for Trace Analysis and Biosensors (TAB-CoE), Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
- Center
of Excellence for Innovation in Chemistry, Faculty of Science, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
- Division
of Health and Applied Sciences, Faculty of Science, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
- Forensic
Science Innovation and Service Center, Prince
of Songkla University, Hat Yai, Songkhla 90110, Thailand
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11
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Ball NS, Knable BM, Relich TA, Smathers AN, Gionfriddo MR, Nemecek BD, Montepara CA, Guarascio AJ, Covvey JR, Zimmerman DE. Xylazine poisoning: a systematic review. Clin Toxicol (Phila) 2022; 60:892-901. [PMID: 35442125 DOI: 10.1080/15563650.2022.2063135] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
PURPOSE Xylazine is an alpha-2-adrenergic agonist used for its sedative and analgesic properties in veterinary medicine. While not approved by the Food and Drug Administration for use in humans, anecdotal evidence suggests that exposures in humans is on the rise. We sought to systematically review and synthesize the evidence on xylazine exposure in humans focusing on the clinical presentation, management, and outcomes. METHODS We conducted a systematic review of the literature including PubMed, Embase, and Scopus from their inception to September 9, 2021. We searched abstracts from selected emergency medicine and toxicology conferences from 2011 through 2021. We included clinical reports of xylazine exposure in humans. We excluded animal studies, in vitro studies, laboratory studies, or articles in a language other than English. From each included article, we extracted subjective and objective data that focused on clinical presentation, management, and outcomes of patients exposed to xylazine. RESULTS We evaluated a total of 1409 records, rendering a final set of 17 articles and 2 abstracts meeting inclusion criteria. We identified a total of 98 patients amongst reports ranging from 1979 to 2020 and across nine countries. The most common types of xylazine exposures reported were unintentional exposure and intentional misuse/abuse. Common symptoms on presentation included hypotension, bradycardia, drowsiness, lethargy, while apnea with intubation and death were less frequently reported. CONCLUSION Human exposure to xylazine appears to be a rising concern within the prehospital and emergency medicine setting. Although a standardized treatment algorithm cannot be recommended at this time, further research is needed to improve the care of patients exposed to xylazine.
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Affiliation(s)
- Noah S Ball
- Duquesne University School of Pharmacy, Pittsburgh, PA
| | | | | | | | | | - Branden D Nemecek
- Duquesne University School of Pharmacy, Pittsburgh, PA.,UPMC Mercy Hospital, Pittsburgh, PA
| | - Courtney A Montepara
- Duquesne University School of Pharmacy, Pittsburgh, PA.,Allegheny General Hospital, Pittsburgh, PA
| | - Anthony J Guarascio
- Duquesne University School of Pharmacy, Pittsburgh, PA.,Allegheny General Hospital, Pittsburgh, PA
| | | | - David E Zimmerman
- Duquesne University School of Pharmacy, Pittsburgh, PA.,UPMC Mercy Hospital, Pittsburgh, PA
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12
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Andresen-Streichert H, Iwersen-Bergmann S, Mueller A, Anders S. Attempted Drug-facilitated Sexual Assault-Xylazine Intoxication in a Child. J Forensic Sci 2016; 62:270-273. [DOI: 10.1111/1556-4029.13270] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2014] [Revised: 03/26/2015] [Accepted: 04/04/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Hilke Andresen-Streichert
- Institute of Legal Medicine; University Medical Center Hamburg - Eppendorf; Butenfeld 34 22529 Hamburg Germany
| | - Stefanie Iwersen-Bergmann
- Institute of Legal Medicine; University Medical Center Hamburg - Eppendorf; Butenfeld 34 22529 Hamburg Germany
| | - Alexander Mueller
- Institute of Legal Medicine; University Medical Center Hamburg - Eppendorf; Butenfeld 34 22529 Hamburg Germany
| | - Sven Anders
- Institute of Legal Medicine; University Medical Center Hamburg - Eppendorf; Butenfeld 34 22529 Hamburg Germany
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13
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Forrester MB. Xylazine Exposures Reported to Texas Poison Centers. J Emerg Med 2016; 51:389-393. [DOI: 10.1016/j.jemermed.2015.09.051] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Accepted: 09/30/2015] [Indexed: 11/30/2022]
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Xylazine Activates Adenosine Monophosphate-Activated Protein Kinase Pathway in the Central Nervous System of Rats. PLoS One 2016; 11:e0153169. [PMID: 27049320 PMCID: PMC4822969 DOI: 10.1371/journal.pone.0153169] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 03/24/2016] [Indexed: 01/03/2023] Open
Abstract
Xylazine is a potent analgesic extensively used in veterinary and animal experimentation. Evidence exists that the analgesic effect can be inhibited using adenosine 5'-monophosphate activated protein kinase (AMPK) inhibitors. Considering this idea, the aim of this study was to investigate whether the AMPK signaling pathway is involved in the central analgesic mechanism of xylazine in the rat. Xylazine was administrated via the intraperitoneal route. Sprague-Dawley rats were sacrificed and the cerebral cortex, cerebellum, hippocampus, thalamus and brainstem were collected for determination of liver kinase B1 (LKB1) and AMPKα mRNA expression using quantitative real-time polymerase chain reaction (qPCR), and phosphorylated LKB1 and AMPKα levels using western blot. The results of our study showed that compared with the control group, xylazine induced significant increases in AMPK activity in the cerebral cortex, hippocampus, thalamus and cerebellum after rats received xylazine (P < 0.01). Increased AMPK activities were accompanied with increased phosphorylation levels of LKB1 in corresponding regions of rats. The protein levels of phosphorylated LKB1 and AMPKα in these regions returned or tended to return to control group levels. However, in the brainstem, phosphorylated LKB1 and AMPKα protein levels were decreased by xylazine compared with the control (P < 0.05). In conclusion, our data indicates that xylazine alters the activities of LKB1 and AMPK in the central nervous system of rats, which suggests that xylazine affects the regulatory signaling pathway of the analgesic mechanism in the rat brain.
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Gao X, Guo H, Du Y, Gu C. Simultaneous Determination of Xylazine and 2,6-Xylidine in Blood and Urine by Auto Solid-Phase Extraction and Ultra High Performance Liquid Chromatography Coupled with Quadrupole-Time of Flight Mass Spectrometry. J Anal Toxicol 2015; 39:444-50. [DOI: 10.1093/jat/bkv040] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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16
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Ruiz-Colón K, Chavez-Arias C, Díaz-Alcalá JE, Martínez MA. Xylazine intoxication in humans and its importance as an emerging adulterant in abused drugs: A comprehensive review of the literature. Forensic Sci Int 2014; 240:1-8. [PMID: 24769343 DOI: 10.1016/j.forsciint.2014.03.015] [Citation(s) in RCA: 106] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Revised: 02/28/2014] [Accepted: 03/12/2014] [Indexed: 10/25/2022]
Abstract
Xylazine is not a controlled substance; it is marketed as a veterinary drug and used as a sedative, analgesic and muscle relaxant. In humans, it could cause central nervous system depression, respiratory depression, bradycardia, hypotension, and even death. There have been publications of 43 cases of xylazine intoxication in humans, in which 21 (49%) were non-fatal scenarios and 22 (51%) resulted in fatalities. Most of the non-fatal cases required medical intervention. Over recent years xylazine has emerged as an adulterant in recreational drugs, such as heroin or speedball (a cocaine and heroin mixture). From the 43 reported cases, 17 (40%) were associated with the use of xylazine as an adulterant of drugs of abuse. Its chronic use is reported to be associated with physical deterioration and skin ulceration. Literature shows some similar pharmacologic effects between xylazine and heroin in humans. These similar pharmacologic effects may create synergistic toxic effects in humans. Therefore, fatalities among drug users may increase due to the use of xylazine as an adulterant. Xylazine alone has proven harmful to humans and even more when it is combined with drugs of abuse. A comprehensive review of the literature of non-fatal and fatal xylazine intoxication cases including those in which the substance was used as adulterant is presented, in order to increase the awareness in the forensic community, law enforcement, and public health agencies.
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Affiliation(s)
- Kazandra Ruiz-Colón
- Puerto Rico Institute of Forensic Sciences, P.O. Box 11878 Caparra Heights Station, San Juan 00922-1878, Puerto Rico.
| | - Carlos Chavez-Arias
- Puerto Rico Institute of Forensic Sciences, P.O. Box 11878 Caparra Heights Station, San Juan 00922-1878, Puerto Rico.
| | | | - María A Martínez
- Instituto Nacional de Toxicología y C. Forenses, Ministerio de Justicia, Las Rozas de Madrid, C/ José Echegaray, 4, 28232 Las Rozas de Madrid, Madrid, Spain.
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Meyer GMJ, Maurer HH. Qualitative metabolism assessment and toxicological detection of xylazine, a veterinary tranquilizer and drug of abuse, in rat and human urine using GC–MS, LC–MS n , and LC–HR-MS n. Anal Bioanal Chem 2013; 405:9779-89. [DOI: 10.1007/s00216-013-7419-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Revised: 09/12/2013] [Accepted: 10/04/2013] [Indexed: 11/30/2022]
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18
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Zheng X, Mi X, Li S, Chen G. Determination of Xylazine and 2,6-Xylidine in Animal Tissues by Liquid Chromatography-Tandem Mass Spectrometry. J Food Sci 2013; 78:T955-9. [DOI: 10.1111/1750-3841.12144] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Accepted: 03/09/2013] [Indexed: 11/29/2022]
Affiliation(s)
- Xiaochun Zheng
- Key Lab of Agro-Product Quality and Safety; Inst. of Quality Standards and Testing Technology for Agro-Products; Chinese Academy of Agricultural Sciences; Beijing; 100081; China
| | - Xiaoxia Mi
- Key Lab of Agro-Product Quality and Safety; Inst. of Quality Standards and Testing Technology for Agro-Products; Chinese Academy of Agricultural Sciences; Beijing; 100081; China
| | - Sicong Li
- Key Lab of Agro-Product Quality and Safety; Inst. of Quality Standards and Testing Technology for Agro-Products; Chinese Academy of Agricultural Sciences; Beijing; 100081; China
| | - Gang Chen
- Key Lab of Agro-Product Quality and Safety; Inst. of Quality Standards and Testing Technology for Agro-Products; Chinese Academy of Agricultural Sciences; Beijing; 100081; China
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Meyer GM, Meyer MR, Mischo B, Schofer O, Maurer HH. Case report of accidental poisoning with the tranquilizer xylazine and the anesthetic ketamine confirmed by qualitative and quantitative toxicological analysis using GC-MS and LC-MSn. Drug Test Anal 2013; 5:785-9. [DOI: 10.1002/dta.1475] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2013] [Revised: 02/20/2013] [Accepted: 02/26/2013] [Indexed: 11/11/2022]
Affiliation(s)
- Golo M.J. Meyer
- Department of Experimental and Clinical Toxicology; Saarland University; D-66421; Homburg (Saar); Germany
| | - Markus R. Meyer
- Department of Experimental and Clinical Toxicology; Saarland University; D-66421; Homburg (Saar); Germany
| | - Bernhard Mischo
- Department of Pediatrics, Marienhausklinik St. Josef Kohlhof; D-66539; Neunkirchen; Germany
| | - Otto Schofer
- Department of Pediatrics, Marienhausklinik St. Josef Kohlhof; D-66539; Neunkirchen; Germany
| | - Hans H. Maurer
- Department of Experimental and Clinical Toxicology; Saarland University; D-66421; Homburg (Saar); Germany
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Reyes JC, Negrón JL, Colón HM, Padilla AM, Millán MY, Matos TD, Robles RR. The emerging of xylazine as a new drug of abuse and its health consequences among drug users in Puerto Rico. J Urban Health 2012; 89:519-26. [PMID: 22391983 PMCID: PMC3368046 DOI: 10.1007/s11524-011-9662-6] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
During the last decade, the veterinary anesthetics have gained popularity as recreational drugs. The aim of this study was to document the use of "anestecia de caballo" (xylazine) and its consequences among drug users in Puerto Rico. The study combined a cross-sectional survey with 89 drug users and two focus groups conducted in Mayagüez with frontline drug treatment providers. Drug users were recruited from communities of the San Juan metropolitan area using a variety of ethnographic and outreach strategies. A short questionnaire developed for the study collected information on sociodemographics, xylazine use, and its consequences. The two focus groups were conducted to discuss the details related to xylazine use, its consequences, and utilization awareness. The sample comprised 63 males (70.8%) and 26 females with a mean age of 37.2 years. The mean number of years of drug use was 14.3, with a mean frequency of drug use of 5.9 times daily. More than 65% reported speedball as the principal drug of use. The prevalence of xylazine use was 80.7%. More than 42% of the sample used xylazine in a mixture with speedball. The main route of administration of xylazine was injection but 14% reported the use of xylazine by inhalation. More than 35% of the sample reported skin lesions and 21.1% reported at least one overdose episode. Multiple logistic regression analysis revealed that males (OR = 3.47, CI = 1.10-12.00) and those who reported speedball as their main drug of use (OR = 9.34, CI = 2.51-34.70) were significantly more likely to be xylazine users. Focus groups revealed that drug users claimed to recognize the presence of xylaxine in a mixture of speedball based on its effects, taste, the color of the drug (dark brown), and its odor. In conclusion, the use of xylazine among drug users in Puerto Rico seems to be an emerging trend with potentially serious health consequences.
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Affiliation(s)
- J C Reyes
- Medical Science Campus Universidad de Puerto Rico, San Juan, Puerto Rico.
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Li P, Han H, Zhai X, He W, Sun L, Hou J. Simultaneous HPLC-UV Determination of Ketamine, Xylazine, and Midazolam in Canine Plasma. J Chromatogr Sci 2012; 50:108-13. [DOI: 10.1093/chromsci/bmr036] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Haymerle A, Fahlman A, Walzer C. Human exposures to immobilising agents: results of an online survey. Vet Rec 2010; 167:327-32. [PMID: 20802186 DOI: 10.1136/vr.c4191] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Cases of human exposure to veterinary injectable anaesthetics were reviewed following a literature search and completion of an online questionnaire in an attempt to provide an objective approach to the problem. The modified Glasgow Coma Scale was used to rank cases according to their severity. From the cases examined, results showed that intoxication with potent opioids, such as etorphine, carfentanil and thiafentanil, need to be treated with antagonists such as naloxone, nalmefene or naltrexone, and not with antagonists with agonistic properties, such as diprenorphine. With regard to the alpha(2)-agonists xylazine, detomidine, medetomidine and romifidine, no antagonist is currently accredited for human use. Atipamezole, a specific alpha(2)-antagonist, is widely used in veterinary medicine and has been used experimentally to reverse dexmetomidine in a study in human medicine. The high concentrations of alpha(2)-agonists being used in zoo and wildlife medicine warrant the accreditation of atipamezole for use in cases of human exposure. Knowledge and availability of the appropriate antagonist are essential in cases of human intoxication with injectable anaesthetics. Preventive measures, such as wearing gloves and eye protection, need to be used more regularly to reduce the risk of exposure.
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Affiliation(s)
- A Haymerle
- Research Institute of Wildlife Ecology, University of Veterinary Medicine, A-1160 Vienna, Austria.
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Wong SC, Curtis JA, Wingert WE. Concurrent detection of heroin, fentanyl, and xylazine in seven drug-related deaths reported from the Philadelphia Medical Examiner's Office. J Forensic Sci 2008; 53:495-8. [PMID: 18284526 DOI: 10.1111/j.1556-4029.2007.00648.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Recreational drugs, such as cocaine and heroin, are often adulterated with other pharmacological agents to either enhance or diminish the drug effects. Between April 21, 2006 and August 8, 2006, the Philadelphia Medical Examiner's Office detected xylazine (a veterinary sedative) and fentanyl (a synthetic opioid) in specimens taken from seven cases. Initial immunoassay screening was performed on urine and blood for fentanyl, opiate, cocaine, phencyclidine (PCP), and benzodiazepines. All tests reported positive were confirmed by gas chromatography-mass spectrometry. All seven xylazine positive cases tested positive for fentanyl and six cases tested positive for 6-acetylmorphine (a metabolite and definitive marker for heroin). The seventh case was positive for morphine and had a history of heroin abuse. Xylazine was present in urine in all seven cases and blood levels were detected in three cases. The blood concentrations ranged from trace to 130 ng/mL. Fentanyl was present in the blood and urine in each case and blood concentrations ranged from 4.7 to 47 ng/mL. Adulteration of illicit drugs has become an epidemic health concern for drug users. Healthcare professionals need to be aware of this issue, so the patients can be treated in an effective, timely manner.
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Affiliation(s)
- Stella C Wong
- Department of Emergency Medicine, Nazareth Hospital, Philadelphia, PA, USA.
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