Psilocybin Exposures Reported to U.S. Poison Centers: National Trends Over a Decade

PURPOSE

We describe trends in psilocybin exposures among adolescents and young adults as reported to US poison centers over the past decade.

METHODS

We queried the National Poison Data System for cases involving psilocybin during January 1, 2013-December 31, 2022. Persons aged 13-25 years were included. We examined exposures to psilocybin by demographics, clinical effects, level of care, and medical outcome.

RESULTS

During the 10-year study period, 4,055 psilocybin-involved exposures were reported among adolescents and young adults, 2,667 (65.8%) being single substance exposures. Most single substance cases received medical attention (adolescents: 75.3% [n = 1,176], young adults: 72.1% [n = 797]). We did not find significant change in the number of cases during 2013-2018. Cases started increasing in 2019. In 2022, cases more than tripled among adolescents and more than doubled among young adults, compared to 2018 (p < .0001).

DISCUSSION

Continued national surveillance is critical to determine the impact of psilocybin exposures on youth as it becomes increasingly available.

Increasing severity of medical outcomes and associated substances in cases reported to United States poison centers

INTRODUCTION

Poison centers provide free expert recommendations on the treatment of a wide variety of toxicological emergencies. Prior studies have called attention to the increasing complexity of cases reported to poison centers. We aimed first, to evaluate the trends in medical outcome severity, over a 15-year period in both the adult and pediatric populations. Second, we described the most frequently reported substances associated with major effect or death.

METHODS

This is a retrospective review of exposures reported to the National Poison Data System from 1 January 2007 through 31 December 2021. All closed cases, for human exposures, reported during the study period were included. We assessed trends in frequencies and rates of medical outcomes and level of care received, among the adult (age greater than 19 years) and pediatric (age 19 years and younger) populations by reason for exposure.

RESULTS

During the study period, the number of adult unintentional exposures resulting in major effect (37.4 percent) and death (65.3 percent) increased. The number of adult intentional exposures resulting in death increased by 233.9 percent and those resulting in a major effect increased by 133.1 percent. The rates of exposures resulting in major effect and death increased among both intentional and unintentional adult exposures. The number of pediatric unintentional exposures resulting in a major effect increased by 76.6 percent and the number of pediatric intentional exposures resulting in death and major effect increased by 122.7 and 190.1 percent, respectively. Moderate, major effect, and death rates increased in pediatric unintentional exposures and moderate and major effect rates increased in pediatric intentional exposures.

CONCLUSIONS

We found a worsening severity of medical outcomes in adult and pediatric cases reported to poison centers. Poison centers are increasingly managing complex cases. Monitoring trends in which substances are associated with severe outcomes is imperative for future strategic prevention efforts.

Using an Exposure Call Center to Help Mitigate Outbreaks, Such as COVID-19, on a University Campus

Rapid identification and management of close contacts is an important component of an effective university mitigation strategy for highly contagious infectious diseases such as measles and coronavirus disease-2019 (COVID-19). Institutions of higher education must plan for an associated large influx of calls that can overwhelm standard student health and local public health operations. In fall 2020, a large state public university's Department of Student Health and Wellness created a dedicated exposure call center (ECC), in close collaboration with the local public health department, to quickly assess students who learned of a COVID-19 exposure outside of the formal contact tracing process. The ECC operated 7 days a week and fielded 3361 calls: 3187 from students and 174 from staff, faculty, and parents. The ECC provided rapid assessment and guidance for students with COVID-19 exposure, allowing for prompt quarantine and medical assessment when warranted. Call centers can increase the bandwidth of university health centers and also reduce the burden on health care providers and other public health resources during periods of crisis or high demand.

Metabolic modeling of sex-specific liver tissue suggests mechanism of differences in toxicological responses

Male subjects in animal and human studies are disproportionately used for toxicological testing. This discrepancy is evidenced in clinical medicine where females are more likely than males to experience liver-related adverse events in response to xenobiotics. While previous work has shown gene expression differences between the sexes, there is a lack of systems-level approaches to understand the direct clinical impact of these differences. Here, we integrate gene expression data with metabolic network models to characterize the impact of transcriptional changes of metabolic genes in the context of sex differences and drug treatment. We used Tasks Inferred from Differential Expression (TIDEs), a reaction-centric approach to analyzing differences in gene expression, to discover that several metabolic pathways exhibit sex differences including glycolysis, fatty acid metabolism, nucleotide metabolism, and xenobiotics metabolism. When TIDEs is used to compare expression differences in treated and untreated hepatocytes, we find several subsystems with differential expression overlap with the sex-altered pathways such as fatty acid metabolism, purine and pyrimidine metabolism, and xenobiotics metabolism. Finally, using sex-specific transcriptomic data, we create individual and averaged male and female liver models and find differences in the pentose phosphate pathway and other metabolic pathways. These results suggest potential sex differences in the contribution of the pentose phosphate pathway to oxidative stress, and we recommend further research into how these reactions respond to hepatotoxic pharmaceuticals.

Suspected Suicide Attempts by Self-Poisoning Among Persons Aged 10-19 Years During the COVID-19 Pandemic - United States, 2020-2022

The World Health Organization declared COVID-19 a global pandemic on March 11, 2020 (1). As strategies to mitigate the pandemic were implemented, concerns were raised that the containment efforts through quarantine and social distancing practices were negatively affecting the mental and physical health of children and adolescents (2). Suicide is a growing public health problem in the United States. In 2020, suicide was the second leading cause of death among persons aged 10-14 years and the third leading cause among those aged 15-24 years (3). The National Poison Data System (NPDS) database was used to examine trends in suspected suicide attempts by self-poisoning among persons aged 10-19 years before and during the COVID-19 pandemic. Compared with 2019 (prepandemic), during 2021, the overall rate of suspected suicide attempts by self-poisoning increased by 30.0% (95% CI = 28.6%-30.9%), rates among children aged 10-12 years, adolescents aged 13-15 years, and females increased 73.0% (67.4%-80.0%), 48.8% (46.7%-50.9%), and 36.8% (35.4%-38.2%), respectively, and these trends continued into the third quarter of 2022. Substances most frequently involved in overdoses were acetaminophen, ibuprofen, sertraline, fluoxetine, and diphenhydramine. Acetaminophen-involved overdoses increased 71% (67.4%-74.9%) in 2021 and 58.0% (54.5%-61.6%) in 2022. Diphenhydramine-involved overdoses increased 24.2% (19.9%-28.7%) in 2021 and 35.8% (31.2%-40.5%) in 2022. A comprehensive public health approach to suicide prevention, focused on children and adolescents and involving a partnership between families, school teachers, mental health professionals, and public health leadership is needed. The 9-8-8 Suicide and Crisis Lifeline provides crisis support for persons experiencing mental health-related distress and assists community members who are concerned about persons experiencing a mental health crisis.

Metabolic modeling of sex-specific tissue predicts mechanisms of differences in toxicological responses

Male subjects in animal and human studies are disproportionately used for toxicological testing. This discrepancy is evidenced in clinical medicine where females are more likely than males to experience liver-related adverse events in response to xenobiotics. While previous work has shown gene expression differences between the sexes, there is a lack of systems-level approaches to understand the direct clinical impact effect of these differences. Here, we integrate gene expression data with metabolic network models to characterize the impact of transcriptional changes of metabolic genes in the context of sex differences and drug treatment. We used Tasks Inferred from Differential Expression (TIDEs), a reaction-centric approach to analyzing differences in gene expression, to discover that androgen, ether lipid, glucocorticoid, tryptophan, and xenobiotic metabolism have more activity in the male liver, and serotonin, melatonin, pentose, glucuronate, and vitamin A metabolism have more activity in the female liver. When TIDEs is used to compare expression differences in treated and untreated hepatocytes, we see little response in those sex-altered subsystems, and the largest differences are in subsystems related to lipid metabolism. Finally, using sex-specific transcriptomic data, we create individual and averaged male and female liver models and find differences in the import of bile acids and salts. This result suggests that the sexually dimorphic behavior of the liver may be caused by differences in enterohepatic recirculation, and we suggest an investigation into sex-specific microbiome composition as an avenue of further research.

Author Summary

Male-bias in clinical testing of drugs has led to a disproportionate number of hepatotoxic events in women. Previous works use gene-by-gene differences in biological sex to explain this discrepancy, but there is little focus on the systematic interactions of these differences. To this end, we use a combination of gene expression data and metabolic modeling to compare metabolic activity between the male and female liver and treated and untreated hepatocytes. We find several subsystems with differential activity in each sex; however, when comparing these subsystems with those pathways altered by hepatotoxic agents, we find little overlap. To explore these differences on a reaction-by-reaction basis, we use the same sex-specific transcriptomic data to contextualize the previously published Human1 human cell metabolic model. In these models we find a difference in flux for the import of bile acids and salts, suggesting a potential difference in enterohepatic circulation. These findings can help guide future drug design, toxicological testing, and sex-specific research to better account for the entire human population.

Identifying vulnerable populations at a university during the COVID-19 pandemic

Objective: Persons with high-risk for severe COVID-19 illness require special attention when considering university operations during the novel coronavirus pandemic. The objective of this study was to determine the number of students who fall within a high-risk category according to Centers for Disease Control and Prevention (CDC) guidelines using linked databases. Participants: Students enrolled at a large public University and who accessed the student health center between 2016 and 2020. Methods: Clinical data were linked with both university student enrollment and disability services databases to provide a comprehensive, de-identified dataset of students at higher medical risk of severe COVID-19 illness. Results: 1902 unique students (14% of the student health center population) were identified as having one or more high-risk condition. Conclusions: Utilizing a large and longitudinally linked student database provides universities with valuable information to make critical administrative decisions about how best to accommodate high-risk students to reduce their medical risk when returning to in-person instruction.

Building-Level Wastewater Surveillance for SARS-CoV-2 in Occupied University Dormitories as an Outbreak Forecasting Tool: One Year Case Study

Congregate living poses one of the highest risk situations for the transmission of respiratory viruses including SARS-CoV-2. University dormitories exemplify such high-risk settings. We demonstrate the value of using building-level SARS-CoV-2 wastewater surveillance as an early warning system to inform when prevalence testing of all building occupants is warranted. Coordinated daily testing of composite wastewater samples and clinical testing in dormitories was used to prompt the screening of otherwise unrecognized infected occupants. We overlay the detection patterns in the context of regular scheduled occupant testing to validate a wastewater detection model. The trend of wastewater positivity largely aligned well with the clinical positivity and epidemiology of dormitory occupants. However, the predictive ability of wastewater-surveillance to detect new positive cases is hampered by convalescent shedding in recovered/noncontagious individuals as they return to the building. Building-level pooled wastewater-surveillance and forecasting is most productive for predicting new cases in low-prevalence instances at the community level. For higher-education facilities and other congregate living settings to remain in operation during a pandemic, a thorough surveillance-based decision-making system is vital. Building-level wastewater monitoring on a daily basis paired with regular testing of individual dormitory occupants is an effective and efficient approach for mitigating outbreaks on university campuses.

Pediatric suicides reported to U.S. poison centers

INTRODUCTION

As the pediatric mental health crisis worsens, the rate of adolescent suicide-related cases is increasing, including adolescent cases of self-poisoning.

METHODS

Data from the National Poison Data System was analyzed for trends in rates and frequencies of all pediatric suspected suicides between 2015 and 2020.

RESULTS

There were 514,350 pediatric suspected suicides analyzed, with the largest increase in rate of suspected suicides occurring in children ages 10 to 12 years (109.3%, p = 0.002). Rates also increased significantly in children ages 13 to 15 years (30.3%, p < 0.001) and 16 to 19 years (18.1%, p < 0.05). The most commonly utilized substances were ibuprofen and acetaminophen, with the largest increase in rate of exposures seen for acetaminophen. Discussion: This data demonstrates concerning rises in cases of self-poisoning, suggesting that the pediatric mental health crisis is worsening and extending into younger populations. Pediatric populations have easier access to over-the-counter medications, potentially explaining the likelihood of utilization of these medications in pediatric suspected suicides.

CONCLUSIONS

Initiation of appropriate mental health screenings and interventions should be considered in these young age groups in order to prevent further rises in self-poisoning cases and associated morbidity and mortality.

A Membrane-Modulated Centrifugal Microdevice for Enzyme-Linked Immunosorbent Assay-Based Detection of Illicit and Misused Drugs

Increased opioid use and misuse have imposed large analytical demands across clinical and forensic sectors. Due to the absence of affordable, accurate, and simple on-site tests (e.g., point of interdiction and bedside), analysis is primarily conducted in centralized laboratories via time-consuming, labor-intensive methods. Many healthcare facilities do not have such analytical capabilities and must send samples to commercial laboratories, increasing turnaround time and care costs, as well as delaying public health warnings regarding the emergence of specific substances. Enzyme-linked immunosorbent assays (ELISAs) are used ubiquitously, despite lengthy workflows that require substantial manual intervention. Faster, reliable analytics are desperately needed to mitigate the mortality and morbidity associated with the current substance use epidemic. We describe one such alternative─a portable centrifugal microfluidic ELISA system that supplants repetitive pipetting with rotationally controlled fluidics. Embedded cellulosic membranes act as microvalves, permitting flow only when centrifugally generated hydraulic pressure exceeds their liquid entry pressure. These features enable stepwise reagent introduction, incubation, and removal simply by tuning rotational frequency. We demonstrate the success of this platform through sensitive, specific colorimetric detection of opiates, a subclass of opioids naturally derived from the opium poppy. Objective image analysis eliminated subjectivity in human color perception and permitted reliable detection of opiates in buffer and artificial urine at the ng/μL range. Opiates were clearly differentiated from other drug classes without interference from common adulterants known to cause false positive results in current colorimetric field tests. Eight samples were simultaneously analyzed in under 1 h, a marked reduction from the traditional multiday timeline. This approach could permit rapid, automatable ELISA-based drug detection outside of traditional laboratories by nontechnical personnel.

COVID-19 Isolation and Quarantine Experience for Residential Students at a Large Four-Year Public University

Rapid identification and management of students with COVID-19 symptoms, exposure, or disease are critical to halting disease spread and protecting public health. We describe the interdisciplinary isolation and quarantine program of a large, public university, the University of Virginia, Charlottesville. The program provided students with wraparound services, including medical, mental health, academic, and other support services during their isolation or quarantine stay. The program successfully accommodated 844 cases during the fall 2020 semester, thereby decreasing exposure to the rest of the university and the local community. (Am J Public Health. 2021;111(10):1772-1775. https://doi.org/10.2105/AJPH.2021.306424).

Toxic Alcohols

This article reviews the background, metabolism, clinical effects, and treatment of toxic alcohols, specifically ethylene glycol, methanol, diethylene glycol, propylene glycol, and isopropyl alcohol. This article also reviews the importance of an anion gap metabolic acidosis in relation to toxic alcohols and explores both the utility and the limitations of the osmole gap in patient management.

Risk factors associated with concussions in a college student population

PURPOSE

To determine risk factors associated with concussion among the general collegiate population using a unique data linkage methodology.

METHODS

Student health medical, counseling, and disability access service data were linked with university enrollment data to provide a comprehensive, deidentified dataset of students who sought care at the student health center for concussion from 2016-2020. Using chi-squared tests and logistic regression, characteristics of students with and without concussion were evaluated.

RESULTS

During the study period, 506 concussions from 474 students were identified (cumulative incidence rate of 51.7 per 10,000 students). Significant predictors of concussion included: younger age (<21 years): odds ratio (OR) = 3.52 (95% confidence intervals [CI], 2.78, 4.50), Greek affiliation: OR = 1.89 (95% CI, 1.56, 2.30), and utilization of counseling and psychological services: OR = 1.92 (95% CI 1.59, 2.32). Of the students with concussion, 47% had at least one other concussion within the preceding year. History of prior hospitalization or medical imaging for head injury increased subsequent concussion risk by 4.5 fold.

CONCLUSIONS

Linking unique datasets provides a richer understanding of the characteristics and risk factors associated with student concussions than analysis of a single data source. This comprehensive dataset will enable future targeted interventions to prevent and treat college student concussions.

Comment on 'effects of acetaminophen on risk taking'

The article by Keaveney et al. entitled ‘Effects of acetaminophen on risk taking’ was published in July of 2020 and concluded that using acetaminophen increased risk-taking behaviors, potentially by reducing perceived risk. We believe that there is not enough data to support the generalization of this association and feel that the conclusions were presented without acknowledgement of the limitations of this study. Media articles often further dramatized these findings, presenting the potential correlation between acetaminophen and risk taking as fact. It is unfair to readers to sensationalize the associations seen in controlled experiments in an attempt to generalize the study’s findings. As scientists, we need to assure that the discussions and conclusions presented in publications appropriately highlight the limitations of studies. We must also work to assure that the public does not sensationalize preliminary and limited research results.

Opioid Exposures Reported to U.S. Poison Centers

OBJECTIVE

Opioid-related deaths are a leading cause of accidental deaths in the United States (U.S.). This study aims to examine the national trends in opioid exposures reported to U.S. poison centers (PCs).

METHODS

The National Poison Data System (NPDS) was queried for opioid exposures between 2011 and 2018. We descriptively assessed the demographic and clinical characteristics. Trends in opioid frequencies and rates were analyzed using Poisson regression. Independent predictors of serious adverse events in opioid exposures were studied.

RESULTS

There were a total of 604,183 opioid exposure calls made to the PCs during the study period. The frequency of opioid exposures decreased by 28.9% (95% CI: -29.6%, -28.1%; p < 0.001), and the rate of opioid exposures decreased by 21.2% (95% CI: -24.7%, -16.9%; p < 0.001). Multiple substance exposures accounted for 48.9% cases. The most frequent age group was 20-29 years (19.3%). Suspected suicides accounted for 34.9% cases. There were 7,246 deaths in our study sample, with 6.8% of cases demonstrating major effects. Hydrocodone was the most frequently observed opioid causing a toxic exposure and naloxone was used in 20.6% cases. Important predictors of a serious adverse event were age, gender, multi-substance exposures, and reasons for exposure.

CONCLUSIONS

Analysis of calls to PCs indicated a decreasing trend of opioid exposures. However, the proportion of SAEs due to such exposures increased. There was a high proportion of intentional exposures and occurred in older age groups. PCs are a vital component of real-time public health surveillance of overdoses in the current opioid crisis.

Comment on “Acetylcysteine in paracetamol poisoning: a perspective of 45 years of use” by D. N. Bateman and J. W. Dear, Toxicol. Res., 2019, 8, 489

We point out an acetylcysteine protocol that a previous article (D. N. Bateman and J. W. Dear, Toxicol. Res., 2019, 8, 489–498) overlooked. The standard concentration protocol uses a uniform concentration of 30 mg mL−1 for all patients to reduce errors in preparation and administration. Usually a single 1 L bag is sufficient for most patients. Various centers in the US and Canada use this approach.

Epidemiology of severe buprenorphine exposures reported to the U.S. Poison Centers

OBJECTIVE

This study aims to evaluate the trends and risk factors of severe buprenorphine outcomes (SBO) reported to the U.S. Poison Centers (PCs).

METHODS

We queried the National Poison Data System for exposures to buprenorphine from 2011 to 2016. SBO cases were defined as exposures that resulted in either a death or major clinical outcomes. Trends were tested using Poisson regression. Characteristics of the exposures were descriptively assessed. Logistic regression was used to evaluate the risk factors of SBO.

RESULTS

SBO cases (967) reported to the PCs increased by 66.6% during this period (114-190, p < 0.001). While adults between 20 and 39 years were more frequent in the SBO group (50.4%) compared to the non-SBO group (38.7%), cases under 6 years (29.6% vs 13.8%) were more common among the non-SBO group. Intentional abuse (20.1% vs 24.9%) and suspected suicides (13.7% vs 37.5%) were significantly higher among the SBO group. Multisubstance exposures were more frequent among the SBO cases (36.4% vs 71.4%). SBO risk increased with age, with cases above 60 years (AOR: 1.66, 95% CI: 1.14-2.42) demonstrating significantly increased odds. Suspected suicide (AOR: 1.87, 95% CI: 1.53-2.28) and abuse (AOR: 1.40, 95% CI: 1.13-1.73) cases were more likely to result in a SBO. Multisubstance exposures significantly increased the risk of a SBO.

CONCLUSIONS

This study reflected an increase in the cases of SBO paralleling the rise in the buprenorphine prescriptions. Age, reasons for exposure and multi-substance exposures significantly increased the risk of SBO.

Women and Addiction: An Update

Gender-related alcohol and drug abuse problems are related not only to biological differences, but also to social and environmental factors, which can influence the clinical presentation, consequences of use, and treatment approaches. Women are becoming the fastest-growing population of substance abusers in the United States. Given that women experience a more rapid progression of their addiction than men, it is important that we understand and address the differences to help develop prevention and treatment programs that are tailored for women, incorporating trauma assessment and management, identification and intervention for medical and psychiatric comorbidities, financial independence, pregnancy, and child care.

Health insurance literacy: A mixed methods study of college students

Objective: This study examines the health insurance literacy, or the ability to use health insurance effectively, of college students. Participants: A total of 455 students from a large, public university completed an online questionnaire in November 2016. Methods: A questionnaire examined students' knowledge of commonly encountered health insurance terms and ability to apply that knowledge to determine cost-sharing in a clinical setting. Results: The majority of students were able to correctly identify the most commonly encountered terms, but could not identify terms related to plan types and options. Eighty-eight percent of students could not determine their cost-sharing for two presented scenarios. Approximately half of the students indicated they had been confused about their health insurance plan, with one-quarter of students stopping or delaying medical care due to confusion. Conclusions: Outreach and education for students should target specific deficits in knowledge such as those identified in this study.

Trends and characteristics of naloxone therapy reported to US poison centers

BACKGROUND AND AIMS

In the United States, access to naloxone has been expanded as a measure to address growing opioid overdose mortality. The study aimed to describe the national trends in naloxone use as reported to the US poison centers (PCs).

METHODS

The National Poison Data System (NPDS) was queried for cases reporting naloxone therapy from 1 January 2001 to 31 December 2016. Demographic and clinical characteristics were assessed descriptively. Trends in naloxone reports were evaluated by using generalized linear mixed models that were adjusted for age, gender and random effects of the geographical census region. Cumulative incidence rates (CIR) of naloxone reports at the state- and national-level were calculated.

RESULTS

There were 304 249 cases reporting naloxone therapy during the study period. The frequency of naloxone reports increased from 9498 in 2000 to 26 826 in 2016. The proportion of cases where naloxone was used prior to PC recommendation increased from 59.8% in 2000 to 81.5% in 2016. The mean number of NPDS naloxone reports per 100 000 human exposures increased from 9.6 [95% confidence interval (CI) = 6.4-14.2] to 31.7 (95% CI = 21.4-46.9, P < 0.001). Among the cases, 52.4% were female and the most frequent age group was 20-39 years (39.1%). The principal reason for a toxic exposure resulting in a naloxone report was suspected suicide (55.0%). Life-threatening symptoms were seen in one-fifth of the cases, with 53.9% cases being admitted to critical care units. Opioids (59.7% cases), were the most commonly reported exposure agents, with hydrocodone being most frequently reported. The national CIR of naloxone reports to the US PCs was 6.3 cases per 100 000 population, with West Virginia demonstrating the highest incidence.

CONCLUSIONS

Analysis of calls to the United States poison centers indicates an increasing trend of naloxone use from 2000 to 2016.

Trends in incidence and risk markers of student emergency department visits with alcohol intoxication in a U.S. public university-A longitudinal data linkage study

BACKGROUND

To examine the trends in incidence and socio-demographic, organizational, academic, and clinical risk markers of student alcohol intoxication associated with emergency department (ED) visits.

METHODS

Student admission data from 2009 to 2015 were linked to primary healthcare data and subsequent ED visits with alcohol intoxication identified using ICD-9 codes within one year following the first (index) enrollment each year. Incidence rate per 10,000 person-years was calculated. Cox proportional hazard regression provided adjusted hazard ratios (HR) (95 % CIs) for the association between student characteristics and subsequent ED visits with alcohol intoxication.

RESULTS

Of 177,128 students aged 16-49 enrolled, 889 had at least one ED visit with alcohol intoxication, resulting in an incidence rate of 59/10,000 person-years. Incidence increased linearly from 45/10,000 person-years in 2009-10 to 71/10,000 person-years in the 2014-15 academic year (p < 0.001). HRs (95%CIs) of student characteristics associated with this outcome were: males (versus females): 1.38 (1.21-1.58); below 20 years of age (versus 25-30 years): 3.36 (1.99-5.65); Hispanic (versus Asian) students: 1.61 (1.16-2.25); parental tax dependency: 1.49 (1.16-1.91); Greek life member: 1.96 (1.69-2.26); member of an athletic team: 0.51 (0.36-0.72); undergraduate (versus graduate) students: 2.65 (1.88-3.74). Past year alcohol use or having been diagnosed with depression or anxiety were also significant predictors. Adjustments for campus-related factors strongly attenuated the associations between student socio-demographic characteristics with this outcome.

CONCLUSIONS

Linking student admission data with ED clinical data can help monitor student alcohol intoxication associated with ED visits and identify student groups at higher risk who subsequently can be targeted for intervention efforts.

Differentials and trends in emergency department visits due to alcohol intoxication and co-occurring conditions among students in a U.S. public university

BACKGROUND

Few studies have explored the epidemiology of students presenting to the emergency department (ED) as a consequence of hazardous drinking. This study examined differentials and trends in ED visits following alcohol intoxication and co-occurring conditions among students presenting to a major U.S. university health system.

METHODS

The ED electronic medical records from academic years 2010-2015 were queried for student visits and their records were linked to the university's student admission datasets. Student alcohol-related visits were identified based on ICD-9 codes. Student characteristics and trends in the rate of alcohol intoxication per 100 ED student visits were analyzed. A random sample of 600 student clinical records were reviewed to validate diagnostic codes.

RESULTS

There were 9616 student ED visits (48% males) to the ED of which 1001 (10.4%) visits involved alcohol intoxication. Two thirds of ED visits with alcohol intoxication had a co-occurring diagnosis, with injuries (24%) being the most common condition. The rate of alcohol intoxication varied greatly by student demographics and campus-related factors. There was a linear increase in the rate of alcohol intoxication from 7.9% in 2009-10 to 12.3% in 2014-15 (p<0.01). The increase was greater among female students, students below 20 years of age, Asian students, and student athletes. In the sample reviewed, only two thirds of ED visits with alcohol intoxication were recorded by diagnostic codes.

CONCLUSION

The rate of ED visits following alcohol intoxication varied by student demographic characteristics and campus-related factors with a rising trend over the study period.

Survival of acute hypernatremia due to massive soy sauce ingestion

BACKGROUND

Intentional massive sodium chloride ingestions are rare occurrences and are often fatal.

OBJECTIVES

There are a variety of treatment recommendations for hypernatremia, ranging from dialysis to varying rates of correction. We report a case of acute severe hypernatremia corrected with rapid free-water infusions that, to our knowledge, has not been previously reported.

CASE REPORT

A 19-year-old man presented to the Emergency Department in a comatose state with seizure-like activity 2 hours after ingesting a quart of soy sauce. He was administered 6 L of free water over 30 min and survived neurologically intact without clinical sequelae. Corrected for hyperglycemia, the patient's peak serum sodium was 196 mmol/L, which, to our knowledge, is the highest documented level in an adult patient to survive an acute sodium ingestion without neurologic deficits.

CONCLUSION

Emergency physicians should consider rapidly lowering serum sodium with hypotonic intravenous fluids as a potential management strategy for acute severe hypernatremia secondary to massive salt ingestion.

Survival of acute hypernatremia due to massive soy sauce ingestion

BACKGROUND

Intentional massive sodium chloride ingestions are rare occurrences and are often fatal.

OBJECTIVES

There are a variety of treatment recommendations for hypernatremia, ranging from dialysis to varying rates of correction. We report a case of acute severe hypernatremia corrected with rapid free-water infusions that, to our knowledge, has not been previously reported.

CASE REPORT

A 19-year-old man presented to the Emergency Department in a comatose state with seizure-like activity 2 hours after ingesting a quart of soy sauce. He was administered 6 L of free water over 30 min and survived neurologically intact without clinical sequelae. Corrected for hyperglycemia, the patient's peak serum sodium was 196 mmol/L, which, to our knowledge, is the highest documented level in an adult patient to survive an acute sodium ingestion without neurologic deficits.

CONCLUSION

Emergency physicians should consider rapidly lowering serum sodium with hypotonic intravenous fluids as a potential management strategy for acute severe hypernatremia secondary to massive salt ingestion.

Toxidromes

The critical care physician is often called to care for poisoned patients. This article reviews the general approach to the poisoned patient, specifically focusing on the utility of the toxidrome. A toxidrome is a constellation of findings, either from the physical examination or from ancillary testing, which may result from any poison. There are numerous toxidromes defined in the medical literature. This article focuses on the more common toxidromes described in clinical toxicology. Although these toxidromes can aid the clinician in narrowing the differential diagnosis, care must be exercised to realize the exceptions and limitations associated with each.

A case of cyanide poisoning and the use of arterial blood gas analysis to direct therapy

Cyanide poisoning is a difficult diagnosis for health care professionals. Existing reports clearly demonstrate that the initial diagnosis is often missed in surreptitious cases. The signs and symptoms can mimic numerous other disease processes. We report a case in which a suicidal patient ingested cyanide and was found unresponsive by 2 laboratory coworkers. The coworkers employed cardiopulmonary resuscitation with mouth-to-mouth resuscitation. The suicidal patient died shortly after arrival to the hospital, while the 2 coworkers who performed mouth-to-mouth resuscitation presented with signs and symptoms that mimicked early cyanide toxicity but were instead due to acute stress response. An arterial blood gas analysis may help aid in the diagnosis of cyanide toxicity. Electrocardiographic findings in a patient with cyanide poisoning range significantly, depending on the stage of the poisoning.

Treatment of chronically digoxin-poisoned patients with a newer digoxin immune fab--a retrospective study

CONTEXT

Digoxin is used in the treatment of patients with cardiac dysfunction, though toxicity sometimes results from the use of this medication. In 1986, the US Food and Drug Administration (FDA) approved a digoxin immune Fab for the treatment of such patients. In 2001, the FDA approved a newer digoxin immune Fab, a digoxin-specific antibody (DSAb) known as DigiFab (Protherics Inc, Brentwood, Tennessee), though minimal literature exists on the clinical effects of this DSAb.

OBJECTIVES

To characterize a cohort of patients presenting with chronic digoxin toxicity and to describe the clinical course of these patients with the use of DSAb.

METHODS

A retrospective study included patients with life-threatening cardiotoxicity and serum digoxin level greater than 2 ng/mL who were treated at two US hospitals from 2003 to 2006. Trained investigators abstracted data from patients' medical records and assessed changes in clinical and laboratory parameters at regular intervals (0-4, >4-12, >12-24, and >24-72 hours) after treatment with DSAb. An expert panel reviewed electrocardiogram results to identify life-threatening manifestations of digoxin toxicity before and after DSAb treatment. Efficacy of treatment was assessed as rates of improvement in clinical parameters and cardiotoxic effects. Rates of adverse drug reactions were used to characterize safety. All data were analyzed with descriptive statistics.

RESULTS

Fourteen patients (mean [SD] age, 71.3 [10.4] years) were treated for chronic digoxin toxicity. At presentation, 12 patients had a heart rate of less than 45 beats per minute, 1 had third-degree heart block, and 1 had asystole. Mean serum digoxin level was 3.6 ng/mL. Eleven patients had abnormal renal function. After administration of DSAb, clinical parameters improved in all patients. Within 24 hours, cardiotoxicity resolved in 7 of 9 evaluable patients. Two adverse drug reactions possibly related to DigiFab occurred, both of which resolved with conventional measures. Two patients died from conditions unrelated to treatment.

CONCLUSION

The newer DSAb appears to be a safe and effective treatment for resolving digoxin toxicity in adults, as indicated by electrocardiogram and clinical assessments. Because patients with multiple comorbidities may be at greater risk for digoxin toxicity, they should be closely monitored during treatment with digoxin.

5-oxoproline-induced anion gap metabolic acidosis after an acute acetaminophen overdose

Metabolic acidosis after acute acetaminophen overdose is typically attributed to either transient lactic acidosis without evidence of hepatic injury or hepatic failure. High levels of the organic acid 5-oxoprolinuria are usually reported in patients with predisposing conditions, such as sepsis, who are treated in a subacute or chronic fashion with acetaminophen. The authors report a case of a 40-year-old woman who developed anion gap metabolic acidosis and somnolence after an acute acetaminophen overdose. Substantial hepatic damage did not occur, which ruled out acetaminophen-induced hepatic insufficiency as a cause of the patient's acidosis or altered mental status. Urinalysis revealed elevated levels of 5-oxoproline, suggesting that the patient's acute acetaminophen overdose was associated with marked anion gap metabolic acidosis due solely to 5-oxoproline without hepatic complications. The acidosis fully resolved with N-acetylcysteine treatment and supportive care including hydration.

Accuracy of internet recommendations for prehospital care of venomous snake bites

OBJECTIVE

To evaluate the accuracy of Internet information regarding the prehospital care of venomous snake bites.

METHODS

Two major search engines were used to identify 48 Web sites regarding 6 prehospital treatment options for snake bite (removal of constrictive devices, ice, heat, electric shock, incision, and suction). Web sites were evaluated for their quality using the Health on the Net (HON) seal and Journal of the American Medical Association (JAMA) benchmarks.

RESULTS

Of the 48 Web sites reviewed, 26 (54.1%) contained inappropriate recommendations. The remaining 22 Web sites were appropriate regarding all modalities addressed. Among the Web sites reviewed, inappropriate treatment recommendations included: suction (14); ice (6); incision (4); electric shock (1). Five Web sites that met all 4 JAMA benchmarks and the HON seal included 3 inappropriate treatment recommendations. Conversely, the 5 Web sites that met none of the JAMA benchmarks nor included the HON seal included only 2 inappropriate treatment measures.

CONCLUSION

This study highlights the variety of misinformation available on the Internet regarding prehospital care of snake bites, and the unreliability of the HON seal and JAMA benchmarks as markers of accuracy. As the Internet becomes an increasing source of medical information for both the public and clinicians, the importance of accurate Web sites becomes imperative. Clinicians and lay people should be aware of the high variability of Internet information regarding snake bite prehospital care.

Ingestion of false hellebore plants can cross-react with a digoxin clinical chemistry assay

INTRODUCTION

We report a case of digoxin-like toxicity because of ingestion of foraged plants. This patient presented with nausea, vomiting, bradycardia, and hypotension after ingesting Veratrum viride (false hellebore). The patient's serum specimen demonstrated a positive digoxin level (0.38 ng/mL) measured by a clinical tubidimetric immunoassay. We hypothesize that steroidal alkaloid compounds contained in V. viride cross-react with the Multigent Digoxin immunoassay reagent antibodies.

RESULTS

Plant extracts from V. viride demonstrated cross-reactivity to Multigent reagent antibodies but did not bind therapeutic DigiFab antibodies. Gas chromatography/mass spectrometry analyses identified several steroidal alkaloid compounds present in the V. viride extracts: jervine, ribigirvine, solanidine, and veratraman.

CONCLUSIONS

This study indicates that compounds extracted from V. viride can cross-react with a clinical Digoxin immunoassay. Yet these extracts did not bind DigiFab antibody fragments used for therapeutic intervention. Providers should not unnecessarily administer DigiFab fragments as an antidote in symptomatic V. viride toxic patients.

Termination of drug-induced torsades de pointes with overdrive pacing

Drug-induced prolongation of the QT interval is frequently encountered after medication overdose. Such toxicity can result in degeneration to torsades de pointes (TdP) and require overdrive pacing. We present 3 cases in which intentional medication overdose resulted in QTc prolongation with subsequent degeneration to TdP. Despite appropriate care, including magnesium therapy, each case required overdrive pacing for resolution of TdP. Although rarely encountered, patients with drug-induced TdP can be successfully managed with overdrive pacing.

Management of the critically poisoned patient

BACKGROUND

Clinicians are often challenged to manage critically ill poison patients. The clinical effects encountered in poisoned patients are dependent on numerous variables, such as the dose, the length of exposure time, and the pre-existing health of the patient. The goal of this article is to introduce the basic concepts for evaluation of poisoned patients and review the appropriate management of such patients based on the currently available literature.

METHODS

An unsystematic review of the medical literature was performed and articles pertaining to human poisoning were obtained. The literature selected was based on the preference and clinical expertise of authors.

DISCUSSION

If a poisoning is recognized early and appropriate testing and supportive care is initiated rapidly, the majority of patient outcomes will be good. Judicious use of antidotes should be practiced and clinicians should clearly understand the indications and contraindications of antidotes prior to administration.