A Narrative Review of Aconite Poisoning and Management

Aconite poisoning refers to toxicity resulting from plants belonging to the Aconitum genus, which comprises over 350 different species of perennial flowering plants that grow in temperate mountainous areas of the northern hemisphere (North America, Europe, Asia). These plants contain a group of toxins known as aconite alkaloids, which encompass numerous closely related toxic compounds. Conventional teaching from toxicology textbooks has broadly classified these alkaloids based on their mechanism of action, often simplifying them as substances that prevent sodium channel inactivation. However, this is an oversimplified and sometimes inaccurate description, as some aconite alkaloids can act as sodium channel blockers. Aconite alkaloids have a long history of use as poisonous substances and have been historically employed for hunting, assassinations, traditional medicine, and self-inflicted harm. Toxicity can occur due to the consumption of traditional medicines derived from aconitum plants or the ingestion of aconite plants and their derivatives. The clinical manifestations of aconite poisoning may encompass gastrointestinal symptoms, sensory alterations, seizures, and life-threatening dysrhythmias that may not respond to standard treatments. Treatment is primarily supportive however evaluation and management of these patients should be personalized and carried out in collaboration with a toxicologist.

The impact of fellowship-trained medical toxicology faculty on emergency medicine resident in-training examination scores

BACKGROUND

The American Board of Emergency Medicine (ABEM) In Training Exam (ITE) gauges residents' medical knowledge and has been shown to correlate with subsequent performance on the ABEM board qualifying examination. It is common for emergency medicine (EM) residencies to employ subspecialty-trained faculty members with the expectation of improved resident education and subspecialty knowledge. We hypothesized that the presence of subspecialty faculty in toxicology would increase residents' scores on the toxicology portion of the ITE.

METHODS

We assessed ABEM ITE scores at our institution from 2013-2022 and compared these to national data. The exposure of interest was the absence or presence of fellowship-trained toxicology faculty. The primary outcome was performance on the toxicology portion of the ITE, and secondary outcome was overall performance on the exam.

RESULTS

Residents who had ≥1 toxicology faculty were 37% (95% CI: 1.01-1.87) more likely to surpass the national average for toxicology scores, and those who had ≥2 toxicology faculty were 77% (95% CI: 1.28-2.44) more likely to surpass the national average for toxicology scores on the ABEM ITE. With the presence of ≥2 toxicology faculty, there was also an increase in toxicology score by years in training, with residents being 63% (95% CI: 1.01-2.64), 68% (95% CI: 1.08-2.61), and 92% (95% CI: 1.01-3.63) more likely to surpass the national average for toxicology score in first, second, and third years of residency, respectively. There was no significant relationship between the presence of toxicology faculty and the overall ABEM ITE scores.

CONCLUSIONS

The presence of fellowship-trained toxicology faculty positively impacted residents' performance on the toxicology portion of the ABEM ITE but did not significantly impact the overall score. With the presence of ≥2 toxicology faculty we noted an improvement in toxicology scores throughout the 3 years of training, indicating that an individual rotation or educational block is probably less important than spaced repetition through a longitudinal curriculum.

The incidence of self-harm ingestions in adolescents and young adults at a tertiary care center

BACKGROUND

There has been an increasing incidence of self-harm attempts in recent years in the United States. Particularly concerning, there has been a growing trend of self-harm in the adolescent and young adult population. In order to inform initiatives to address this trend, risk factors and substances used for self-harm need to be clarified.

METHODS

This is a descriptive retrospective observational study on all cases of self-harm poisoning in patients between the ages of 12 and 25 years reported at the state's only tertiary care center from January 2019 through March 2022.

RESULTS

There was an increased incidence of 69% for self-harm poisonings for all ages and a 90% increase in ages 12-17 years between the years 2019 and 2021. Fifty percent of all cases occurred in patients aged 14-17 years, 69% were female, and 22% required an intensive care unit. The top three most common substances used are available without a prescription.

DISCUSSION

There was a persistent increase in self-harm attempts via poisoning throughout the study period with a particularly vulnerable period in the adolescent age group.

Applying Project ECHO (Extension for Community Health Care Outcomes) to improve addiction care in rural emergency departments

Background

Advancements in research and legislation have improved emergency provider ability to treat opioid use disorder (OUD), but dissemination into rural emergency departments (EDs) is limited. Project Extension for Community Healthcare Outcomes (ECHO) allows community generalists to learn from specialists through telementoring. We aimed to use ECHO to facilitate knowledge translation, increase confidence, and change behavior of rural ED providers treating patients with OUD.

Methods

Stakeholder interviews were conducted with rural ED providers. A group of ED addiction experts created an ECHO curriculum with eight OUD topics. ED health professionals were recruited and completed pre/post surveys centered around knowledge and comfort with treating OUD in the ED, with focus on clinical practice and stigma. Following the ECHO model, sessions included a 20-min didactic followed by two cases presented by participants, with discussion facilitated by faculty.

Results

Twenty-seven participants registered; seven attended ≥75% of sessions and completed both surveys. Of the seven, three were physicians, two advanced practice providers, one nurse, and one clinical pharmacist. Eight 1-hour sessions were conducted in two cohorts between January and December 2021. On a 5-point Likert scale, respondents on average agreed with questions evaluating acceptability (mean ± SD 3.96 ± 0.64), appropriateness (mean ± SD 4.18 ± 1.18), and feasibility (mean ± SD 4.00 ± 1.17). Participants had a 1.09-point increase (paired t-test = 2.43, p = 0.05) on 7-point Likert-scale questions measuring self-efficacy and a 0.13-point change (paired t-test = 2.64, p = 0.04) on 4-point Likert scale questions measuring stigmatizing attitudes (reduction of attitudes). A total of 71% (5/7) reported changes in clinical practice and 57% (4/7) in departmental protocols after participation.

Conclusions

Our ED OUD ECHO course successfully created a model for rural ED providers to learn from ED addiction experts. It was well received and impacted self-reported provider stigmatizing attitudes, patient-facing behavior, and departmental initiatives. Recruitment was challenging and participation was limited. Future efforts will target maximizing recruitment.

A Fatal Colchicine Ingestion With Antemortem Blood Concentration

ABSTRACT

Although there are multiple therapeutic uses for colchicine, it is particularly dangerous in the setting of overdose due to an irreversible mechanism of action combined with a narrow therapeutic window. Colchicine is an antimitotic agent that binds tubulin and inhibits microtubule polymerization. This produces a predictable sequence of toxicity beginning with gastrointestinal effects with progression to multiorgan system dysfunction. Unfortunately, there are no specific antidotes for colchicine toxicity after organ injury has occurred, which can lead to tragic consequences. Despite the recognized toxicity, it is exceedingly rare to find a case in the medical literature with a confirmed time of ingestion, amount ingested, data from longitudinal examinations, and laboratory assessments, with a quantitative blood colchicine concentration. We present a case of acute colchicine overdose of 18 mg (approximately 0.25 mg/kg) with subsequent multiorgan failure and death with an antemortem blood colchicine concentration of 14 ng/mL at 18.5 hours after ingestion.

Severe chronic Carboxyhemoglobinemia and polycythemia due to smoking hookah

Acute carbon monoxide (CO) poisoning due to smoking hookah has been reported and may present similarly to other causes of acute carbon monoxide poisoning with nausea, headache, and loss of consciousness [1]. In the acute poisoned patient, immediate removal from the carbon monoxide source is paramount in addition to administration of oxygen and possible hyperbaric oxygen therapy (HBO) in certain situations. However, cases of chronic CO poisoning, treatment options, and long-term adverse health effects are far less reported but may include atherosclerosis and vague neurologic symptoms [2]. We present a case of a patient who chronically smoked hookah creating a condition of chronic carboxyhemoglobinemia which was discovered during work up for unexplained polycythemia. While being seen in the hematology clinic, he was found to have a blood carboxyhemoglobin of level 33.6% despite being asymptomatic. This is the highest recorded hookah-related carboxyhemoglobin concentration in the medical literature; and the significant chronic carboxyhemoglobinemia explained his polycythemia. This case illustrates that a social history is crucial when assessing the patient with severe carboxyhemoglobinemia as HBO is not indicated in chronic CO poisoning in an asymptomatic patient.

The Timing of Clinical Effects of Bupropion Misuse Via Insufflation Reported to a Regional Poison Center

BACKGROUND

Bupropion is an antidepressant medication with expanding indications including smoking cessation, weight loss, attention-deficit/hyperactivity disorder, seasonal affective disorder, and amphetamine dependence. Despite its increasing popularity among providers, it has a well-known narrow therapeutic window that can lead to delayed onset of symptoms with extended-release formulations and devastating consequences in overdose. We have noticed some patients misusing bupropion via insufflation, which added a layer of complexity with regards to the therapeutic application of the drug. This route of use created difficult decisions regarding clinical monitoring in these patients.

OBJECTIVES

To determine if prolonged observation is required after insufflation of bupropion and to further describe effects from this route of use.

METHODS

This is a retrospective observational study reviewing all the cases of insufflated bupropion use reported to a single poison center without any other coingestants.

RESULTS

The majority (85.7%) of patients had mild or moderate effects, and seizures occurred in 19.6% of cases; and the vast majority of patients were symptomatic by the time of the initial call to the poison center. We did not encounter any delayed effects after this route of use.

CONCLUSIONS

This report describes the clinical effects reported, and the timing of these effects, after insufflation of bupropion.

Clinical effects of intravenous bupropion misuse reported to a regional poison center

Bupropion is an antidepressant medication with expanding indications including smoking cessation, weight loss, attention-deficit/hyperactivity disorder, seasonal affective disorder, and amphetamine dependence. Despite its increasing popularity among providers, it has a well-known narrow therapeutic window which can lead to delayed onset of symptoms with extended-release formulations and devastating consequences in overdose. We have noticed some patients misusing bupropion via intravenous use and had difficulty guiding decisions regarding clinical monitoring in these patients. As this route entirely changes the kinetics of bupropion, this has caused concern within our group. We reviewed all the cases of intravenous bupropion use reported to a single poison center without any other coingestants. The majority (66.7%) of patients had moderate effects and one patient had a seizure. No deaths were reported. All patients were symptomatic by the time of initial call to the poison center if they had any reported symptoms due to bupropion. This case series describes the clinical effects reported, and the timing of these effects, after intravenous bupropion use.

Hemodialysis in metformin-associated lactic acidosis due to acute overdose in a metformin-naïve patient

Metformin is a common and generally well-tolerated medication in the treatment of diabetes but rarely has been implicated as the cause for metformin-associated lactate acidosis. This is usually caused by decreased elimination from renal dysfunction but is rarely described after an acute ingestion. We present a case of an acute intentional overdose of metformin in a metformin-naïve patient without renal dysfunction. The patient gradually developed altered mental status, tachypnea, hypotension, hyperglycemia, hypoglycemia, hypothermia, and vasoplegic shock unresponsive to vasopressor support. Despite attempts at alkalinization, the patient developed a lactic acidosis with a pH of 6.9 and lactate of 33 mmol/L. Hemodialysis was performed with rapid improvement of clinical status. This case provides a clinical context in the acute setting and illustrates the rare need for extracorporeal support in this setting, which may be lifesaving.

Chondrogenic progenitor cells respond to cartilage injury

OBJECTIVE

Hypocellularity resulting from chondrocyte death in the aftermath of mechanical injury is thought to contribute to posttraumatic osteoarthritis. However, we observed that nonviable areas in cartilage injured by blunt impact were repopulated within 7-14 days by cells that appeared to migrate from the surrounding matrix. The aim of this study was to assess our hypothesis that the migrating cell population included chondrogenic progenitor cells that were drawn to injured cartilage by alarmins.

METHODS

Osteochondral explants obtained from mature cattle were injured by blunt impact or scratching, resulting in localized chondrocyte death. Injured sites were serially imaged by confocal microscopy, and migrating cells were evaluated for chondrogenic progenitor characteristics. Chemotaxis assays were used to measure the responses to chemokines, injury-conditioned medium, dead cell debris, and high mobility group box chromosomal protein 1 (HMGB-1).

RESULTS

Migrating cells were highly clonogenic and multipotent and expressed markers associated with chondrogenic progenitor cells. Compared with chondrocytes, these cells overexpressed genes involved in proliferation and migration and underexpressed cartilage matrix genes. They were more active than chondrocytes in chemotaxis assays and responded to cell lysates, conditioned medium, and HMGB-1. Glycyrrhizin, a chelator of HMGB-1 and a blocking antibody to receptor for advanced glycation end products (RAGE), inhibited responses to cell debris and conditioned medium and reduced the numbers of migrating cells on injured explants.

CONCLUSION

Injuries that caused chondrocyte death stimulated the emergence and homing of chondrogenic progenitor cells, in part via HMGB-1 release and RAGE-mediated chemotaxis. Their repopulation of the matrix could promote the repair of chondral damage that might otherwise contribute to progressive cartilage loss.

Repeated measurement of mechanical properties in viable osteochondral explants following a single blunt impact injury

The objective of this work was to develop a method for repeated same-site measurement of mechanical properties suitable for the detection of degenerative changes in a biologically active explant model after a single blunt impact injury. Focal blunt impact injuries to articular surfaces lead to local cartilage degeneration and loss of mechanical properties. We employed a repeated measurement methodology to determine variations in mechanical same-site properties before and after injury in living cartilage, with the hypothesis that normalization with initial mechanical properties may provide a clearer evaluation of impact effects and improve our understanding of the biologic responses to impact injury. Bovine osteochondral explants were cultured for up to 14 days after impact injury. Indentation tests were performed before and after impact injury to assess relative changes in mechanical properties. Creep strain increased significantly in impacted explants after 7 days and in both impacted and control explants after 14 days. Further analysis at 14 days revealed decreases in stretch factor beta, creep time constant and local compressive modulus. A repeated measures methodology reliably detected changes in the mechanical behaviour of viable osteochondral explants after a single impact injury.

Zebra mussels affect benthic predator foraging success and habitat choice on soft sediments

The introduction of zebra mussels ( Dreissena spp.) to North America has resulted in dramatic changes to the complexity of benthic habitats. Changes in habitat complexity may have profound effects on predator-prey interactions in aquatic communities. Increased habitat complexity may affect prey and predator dynamics by reducing encounter rates and foraging success. Zebra mussels form thick contiguous colonies on both hard and soft substrates. While the colonization of substrata by zebra mussels has generally resulted in an increase in both the abundance and diversity of benthic invertebrate communities, it is not well known how these changes affect the foraging efficiencies of predators that prey on benthic invertebrates. We examined the effect of zebra mussels on the foraging success of four benthic predators with diverse prey-detection modalities that commonly forage in soft substrates: slimy sculpin ( Cottus cognatus), brown bullhead ( Ameirus nebulosus), log perch ( Percina caprodes), and crayfish ( Orconectes propinquus). We conducted laboratory experiments to assess the impact of zebra mussels on the foraging success of predators using a variety of prey species. We also examined habitat use by each predator over different time periods. Zebra mussel colonization of soft sediments significantly reduced the foraging efficiencies of all predators. However, the effect was dependent upon prey type. All four predators spent more time in zebra mussel habitat than in either gravel or bare sand. The overall effect of zebra mussels on benthic-feeding fishes is likely to involve a trade-off between the advantages of increased density of some prey types balanced against the reduction in foraging success resulting from potential refugia offered in the complex habitat created by zebra mussels.

Typical Friedreich's ataxia without GAA expansions and GAA expansion without typical Friedreich's ataxia

We clinically assessed and performed polymerase chain reaction analysis for the GAA trinucleotide repeat expansion in 103 patients from 73 families in Ireland, with a prior clinical diagnosis of Friedreich's ataxia (FA) or an unclassified progressive ataxic syndrome. The patients were classified as "typical" or "atypical" FA according to Harding's mandatory clinical diagnostic criteria. All patients underwent blood glucose analysis, and electrocardiography and echocardiography was performed in 99 and 101 patients, respectively. Mutation screening for expanded CAG trinucleotide repeats, associated with spinocerebellar ataxia (SCA) 1, 2, 3 and 6 was performed in 86 patients overall, including all GAA negative patients. Forty-nine of 56 typical patients and 13 of 47 atypical patients were either homozygous or heterozygous for the GAA expansion. Seven patients with a typical FA phenotype were negative for the GAA expansion. Although one of these patients had vitamin E deficiency, and two had raised alpha-fetoprotein levels, three other GAA negative patients with a typical FA phenotype had no other identifiable cause for their ataxia, once again raising the possibility of locus heterogeneity in FA. It is also possible that these patients have two point mutations in the X25 gene, or that they have another ataxic syndrome mimicking the FA phenotype. Two families who were homozygous for the GAA expansion exhibited intrafamilial phenotypic variability. Only one GAA negative patient had the SCA 3 mutation, and this was the only patient in the study with a possible autosomal dominant inheritance pattern. In the homozygous GAA population typical patients had significantly more repeats on the smaller allele than atypical patients, and there was an inverse relationship between the number of repeats on the smaller allele and the age at presentation. There was also an inverse relationship between the repeat size on both the larger and the smaller of the two alleles and the age at becoming wheelchair bound. There was no significant relationship between repeat size and the other indices of disease severity, including the presence or absence of diabetes or cardiomyopathy. This is the first large study of an Irish population with progressive ataxia that has shown a similar phenotype/genotype relationship to studies of FA in other European and non-European populations. The relatively low sensitivity and specificity of Harding's clinical diagnostic criteria must be appreciated when clinically assessing patients with a progressive ataxic syndrome. Although molecular genetic analysis now plays an essential role in diagnosis and classification, patients with a typical FA phenotype without any identifiable cause for their ataxia exist.

Amnesic syndrome with bilateral mesial temporal lobe involvement in Hashimoto's encephalopathy

A 25-year-old woman presented with a subacute confusional state, headaches, unsteadiness, myoclonus, seizures, and an amnesic syndrome as a manifestation of Hashimoto's encephalopathy. Investigations showed biochemical hypothyroidism, raised thyroid microsomal antibodies, and weakly positive antineuronal antibodies. A T2-weighted MRI of the brain showed bilateral symmetric areas of increased signal in the mesial temporal lobes and hippocampi that had a low signal intensity on T1-weighted imaging. Despite clinical and radiologic improvement after steroid and thyroid hormone replacement therapy, a severe amnesic syndrome with associated localized MRI abnormalities persists.

Prevention of ischaemic stroke--antiplatelets

Aspirin is the treatment of first choice for long-term secondary prevention of vascular events in patients with confirmed non-cardioembolic ischaemic stroke or TIA. However, there is no good evidence that it is of benefit in primary stroke prevention. If aspirin is contra-indicated, dipyridamole monotherapy is a relatively cheap, but slightly less effective, alternative. Aspirin and dipyridamole have an additive effect in secondary stroke prevention, but there is a high incidence of side effects and subsequent discontinuation of treatment with combination therapy. It is reasonable to consider clopidogrel for secondary prevention of vascular events in patients with ischaemic stroke who are intolerant of aspirin or dipyridamole, or who have a history of ischaemic heart disease. However, its cost is considerable. Over the next decade, oral antiplatelet agents directed against specific platelet receptors, or a combination of antiplatelet drugs inhibiting different aspects of platelet function, may improve secondary prevention of stroke.

Fatal cerebral reperfusion hemorrhage after carotid stenting

BACKGROUND

The hyperperfusion syndrome is a recognized complication of carotid endarterectomy. Reports of cerebral hyperperfusion injury following internal carotid artery (ICA) angioplasty are few, and this complication has never been reported following internal carotid stenting.

CASE DESCRIPTION

A 68-year-old normotensive man was referred to our hospital for assessment 5 months after experiencing a left hemispheric ischemic stroke. Angiography confirmed 95% stenosis of the left ICA. Left carotid percutaneous transluminal stenting was performed without any initial complications. Color Doppler ultrasound of the ICA immediately after stenting revealed an elevated peak systolic velocity of 2.3 m/s, in the absence of significant vessel stenosis or spasm on angiography. Seven hours after the procedure, the patient suddenly deteriorated. CT of the brain revealed extensive intracerebral hemorrhage (ICH), and he subsequently died 18 days later. There was no history of headache or seizure activity, and his blood pressure was only mildly elevated at the time of the deterioration. This is the first report of ICH after internal carotid stenting.

CONCLUSIONS

ICH may occur as a hyperperfusion phenomenon after internal carotid stenting, in the presence of mild to moderate arterial hypertension, without being heralded by any of the typical symptoms of the hyperperfusion syndrome. Patients with increased velocities on color Doppler ultrasound of the ICA after angioplasty should be monitored closely for features of cerebral hyperperfusion injury. Further studies are warranted to determine whether more aggressive treatment of mild to moderate hypertension after carotid stenting would reduce the likelihood of this potentially fatal complication.

Multivariate Relationships Between Job Characteristics And Job Satisfaction In The Public Sector: A Triple Cross-Validation Study

This study investigated multivariate relationships between task characteristics, measured by the Job Diagnostic Survey, and satisfaction with work outcomes, measured by the Triple Audit Opinion Survey, for 1,972 workers in the public sector. The obtained canonical correlations were high and stable across independent samples of public employees as indicated by a triple cross-validation design. The results support the predictions derived from the Hackman and Oldham model that job characteristics are more important for feelings of intrinsic job satisfaction than feelings of extrinsic job satisfaction, and that job characteristic - job satisfaction relationships are higher for high self-actualization need strength employees than for low self-actualization need strength employees. It was concluded that previous job characteristic - job satisfaction relationships established for private sector employees can be generalized to public sector employees.