Faculty Bibliography

Background: SCRAs are popular novel drugs of abuse. Despite their banning, use has skyrocketed in the USA. Current emergency department (ED) presentations highlight the varied clinical effects associated with reported SCRA use. Hypothesis: In this Department of Health investigation, we confirm SCRA use with biological testing and hypothesize that toxicity is predictable based on SCRA classification.
Method(s): Since May 2015, ED patients reporting 'K2' use with SCRA toxicity were identified. Those in possession of suspected SCRA product(s) had blood and urine specimens obtained and clinical features reported to the Poison Center (PC). Blood, urine, and product samples were linked with clinical effects but de-identified from the patient and kept in a separate, secure database. Specimens were stored and shipped at -20 degreeC to an independent laboratory for analysis. This public health surveillance investigation was approved by our local department of health.
Result(s): In this preliminary report, six product and seven biological results from 10 patients were available for analysis. SCRAs found in products included the following: NM2201, MAB-Chiminaca, XLR11, AMB, AB-Chiminaca, and MDMB-Fubinaca, with some products containing multiple SCRAs. SCRAs found in biological specimens included the following: MAB-Chiminaca, MABChiminaca metabolites, and AB-Chiminaca metabolites. Not all SCRAs found in products could be identified in corresponding patient biological specimens. Some SCRAs found in biological specimens were not found in corresponding products. In patients with confirmed MAB-Chiminaca in biological specimens (n = 4), one had agitation and three presented with central nervous system (CNS) depression. CNS depression (n = 1), delirium (n = 1), and seizure (n=1) were reported in patients with biological confirmation of AB-Chiminaca.
Discussion(s): Preliminary data from this Department of Health investigation identified multiple SCRAs in products and biological specimens. Clinical effects varied from sedation to agitation in patients with the same SCRAs. This variability may result from dose-dependent effects, individual host factors, or co-exposures. Not all suspected SCRAs or their metabolites can easily be identified in biological specimens. It is unclear if the 'K2' products obtained from the patients were the exact products used.
Conclusion(s): Individuals can develop varied toxicity after using the same SCRA. This surveillance project is still ongoing and additional results will be available in the future

Background: Salicylate (ASA) poisoning remains a significant public health threat with upwards of 20,000 exposures annually in the USA and morbidity/mortality rates of up to 25 %. Identifying predictors of severe outcome allows for targeted treatment to lower these rates. Research Question:What factors are early predictors of severe in-hospital outcomes in ED patients presenting with ASA poisoning? Methods: This was a secondary data analysis of ASA overdoses from a prospective cohort study of suspected acute drug overdoses at two urban university teaching hospitals from 2009 to 2013. Patients were enrolled consecutively and were considered eligible for inclusion based on clinical suspicion of ASA ingestion. Children (<18) and alternate diagnoses were excluded. Demographics, clinical parameters, serum ASA concentrations, treatment modalities, and death/admission rate were collected from the medical record. Severe outcome was defined as a composite occurrence of any of the following: acidemia (pH <7.3 or bicarbonate <16 mEq/L), hemodialysis, or death.
Result(s): Forty-eight patients met inclusion criteria, with 43.8 % male, median age 32, mean initial ASA concentration 28.1, and 10 (21 %) classified as severe outcome. There were two deaths, neither of whom received hemodialysis. Patients were treated with sodium bicarbonate in one third of cases, while 54.2 % received activated charcoal and 64.6 % were admitted. Univariate analysis indicated that age (p = 0.04, t test), respiratory rate (RR) (p = 0.04, t test), creatinine (p = 0.05, t test), lactate (p = 0.002, t test), coma (p = 0.05, chi square), and presence of co-ingestions (p = 0.04, chi square) were significantly associated with severe outcome, while ASA alone had no association. However, when adjusted for serum ASA concentration, only age (OR 1.02 per additional year, CI 1.0-1.1), RR (1.09 per additional breath/min, CI 1.03-1.15), creatinine (2.8 per additional mg/dL CI 1.1-7.1), and co-ingestions (OR 6.4, CI 2.3-17.8) were independent predictors of severe outcome.
Discussion(s): We have derived independent predictors of severe outcome from acute ASA poisoning, which can aid in identifying patients who require more aggressive treatment, and does not include serum ASA concentration. Despite the severity of these cases, only one third received sodium bicarbonate, suggesting potential barriers to administration which require further study.
Conclusion(s): Age, RR, creatinine, and co-ingestions are predictive of severe outcome in ED patients with acute ASA poisonin

INTRODUCTION: Invasive meningococcal disease can be difficult to detect early in its course when patients may appear well and the severity of their illness is obscured by non-specific complaints. CASE PRESENTATION: We report five cases of meningococcal sepsis in adult patients who presented to an emergency department early in the course of their disease, but whose severity of illness was not recognized. CONCLUSION: Suspicion of meningococcal sepsis should be heightened in the setting of hypotension, tachycardia, elevated shock index, leukopaenia with left shift, thrombocytopaenia and hypokalaemia, prompting early sepsis care.