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

Context Although the clinical use of intravenous lipid emulsion therapy for the treatment of lipophilic drug toxicity is increasing, the focus of most publications is on outcome in laboratory animals or in patients. An unintended consequence of intravenous lipid emulsion is the creation of extremely lipemic blood, which may interfere with the laboratory analysis or interpretation of common analytes. Objective The American Academy of Clinical Toxicology has established a lipid emulsion workgroup to review the evidence and produce recommendations on the use of this novel therapy for drug toxicity. The aim of this subgroup is to review the available evidence regarding the effect of intravenous lipid emulsion on common laboratory testing, which often forms the basis of the appraisal of the balance between benefits and potential adverse events. Methods We performed a comprehensive review of the literature. Relevant articles were determined based upon a predefined methodology. Package inserts of manufacturers' assays were collected. Article inclusion required that the article met predefined inclusion criteria with the agreement of at least two members of the subgroup. Results We included thirty-six articles in the final analysis. Evaluation of the reviewed analytes revealed heterogeneity with regards to the assessment of the effect of intravenous lipid emulsion in terms of consistency and magnitude of effect across the different analytic platforms. Conclusions The measurements of a number of common analytes can be markedly affected by the lipemia produced by lipid emulsions such that they cannot always be interpreted in the way that most physicians use this information in typical clinical situations. In fact, a lack of appreciation of this effect may lead to unintentional treatment errors. Because the effect of the lipemia produced is dependent on the reagents and laboratory platform used, it would be useful for all future reports to clearly document sample handling, reagents and laboratory platform used, as well as any procedures employed to reduce the lipid content.

BACKGROUND: Novel psychoactive substances (NPS) are emerging at an unprecedented rate. Likewise, prevalence of use and poisonings has increased in recent years. OBJECTIVE: To compare characteristics of NPS exposures and non-NPS-drug-related exposures and to examine whether there are differences between exposures involving synthetic cannabinoid receptor agonists (SCRAs) and other NPS. METHODS: Poison control center data from the five counties of New York City and Long Island were examined from 2011-2014. We examined prevalence and characteristics of NPS exposures (classified as intentional abuse) and compared characteristics of cases involving SCRAs and other NPS. RESULTS: Prevalence of NPS exposures was 7.1% in 2011, rising to 12.6% in 2014. Most exposures (82.3%) involved SCRA use. The second and third most prevalent classes were phenethylamines/synthetic cathinones ("bath salts"; 10.2%) and psychedelic phenethylamines (4.3%). Compared to other drug-related exposures (i.e. involving licit and illicit drugs), those who used NPS were more likely to be younger, male, and to have not co-used other drugs (ps < 0.001). SCRA exposures increased sharply in 2014 and the mean age of users increased over time (p < 0.01). Females exposed to SCRAs were younger than males (p < 0.001), and in 2014, individuals exposed to SCRAs were more likely to report concomitant use of alcohol than users of other NPS (p = 0.010). Users of other NPS were more likely than SCRA users to report concomitant use of ecstasy/3,4-methylenedioxymethamphetamine (MDMA)/"Molly" (p < 0.001). CONCLUSION: Exposures reported to the poison center that involve NPS are increasing and the majority involve SCRAs. These findings should inform prevention and harm reduction approaches.

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