Faculty Bibliography

Background: Metformin is the most commonly prescribed antiglycemic agent in the USA. Some have suggested that the potential for metabolicacidosis and hyperlactatemia is spurious in patients taking this medication. Hypothesis:We hypothesize thatmetabolic acidosis with hyperlactatemia occurs not infrequently in patients taking metformin.
Method(s): We retrospectively analyzed Toxicology Investigators Consortium (ToxIC) registry data from January 1, 2010 to September 30, 2015. We searched for all patients with metformin toxicity, with emphasis on metabolic acidosis (pH < 7.2) and lactate concentrations. We reviewed demographics, laboratory analyses, co-exposures, treatments, and survival.
Result(s): Seventy-seven cases with metformin listed as 'primary agent, most consequential' were available for analysis. Intent was reported as intentional overdose (n = 65), unintentional (n = 9), adverse drug reaction (n = 2), and drug abuse (n = 1). Of 65 intentional ingestions, all of which were acute, the dose was reported in 12 (range, 4-100 g). Co-exposures were present in 47 (72.3 %). Twelve (18.5 %) cases reported no sequelae. Ten (15 %) experienced a blood glucose <50 mg/dL. Twenty patients (31 %) had a pH <7.2, with an additional six (9.2 %) with an anion gap (AG) >20. Lactate was reported in 17 cases ofmetformin exposure (mean, 3 mmol/L; range 0.17-27.99 mmol/L). In patients coded with metabolic acidosis (n = 7), the mean serum lactate was 4.91 mmol/L (range, 0.44- 27.99mmol/L). Nine patients (13.8%) had acute kidney injury (creatinine >2.0 mg/dL). Four patients were decontaminated with activated charcoal; one received gastric lavage. Interventions included sodium bicarbonate (18.5 %), hemodialysis (12.3 %), and continuous renal replacement therapy (7.7 %). Hypoglycemic patients received glucose >5 %. No fatalities were reported.
Discussion(s): In ToxIC, the majority of metformin exposures were acute, intentional overdoses. Approximately 40 % of the patients with metformin overdoses in ToxIC had metabolic acidosis (pH <7.2 or AG >20). Our analysis of lactate was limited as it was not specifically included in ToxIC until 2015. Renal insufficiency occurred in 13.8 % of patients.
Conclusion(s): Metabolic acidosis was present in a significant number of patients with acute metformin exposures. Providers should be cognizant of this significant toxicity

OBJECTIVE: To evaluate the acute impact of disasters on diabetic patients, we performed a geospatial analysis of emergency department (ED) use by New York City diabetic adults in the week after Hurricane Sandy. RESEARCH DESIGN AND METHODS: Using an all-payer claims database, we retrospectively analyzed the demographics, insurance status, and medical comorbidities of post-disaster ED patients with diabetes who lived in the most geographically vulnerable areas. We compared the patterns of ED use among diabetic adults in the first week after Hurricane Sandy's landfall to utilization before the disaster in 2012. RESULTS: In the highest level evacuation zone in New York City, postdisaster increases in ED visits for a primary or secondary diagnosis of diabetes were attributable to a significantly higher proportion of Medicare patients. Emergency visits for a primary diagnosis of diabetes had an increased frequency of certain comorbidities, including hypertension, recent procedure, and chronic skin ulcers. Patients with a history of diabetes visited EDs in increased numbers after Hurricane Sandy for a primary diagnosis of myocardial infarction, prescription refills, drug dependence, dialysis, among other conditions. CONCLUSIONS: We found that diabetic adults aged 65 years and older are especially at risk for requiring postdisaster emergency care compared to other vulnerable populations. Our findings also suggest that there is a need to support diabetic adults particularly in the week after a disaster by ensuring access to medications, aftercare for patients who had a recent procedure, and optimize their cardiovascular health to reduce the risk of heart attacks.

OBJECTIVE: To assess the impact of an emergency intensive care unit (EICU) established concomitantly with a freestanding emergency department (ED) during the aftermath of Hurricane Sandy. METHODS: We retrospectively reviewed records of all patients in Bellevue's EICU from freestanding ED opening (December 10, 2012) until hospital inpatient reopening (February 7, 2013). Temporal and clinical data, and disposition upon EICU arrival, and ultimate disposition were evaluated. RESULTS: Two hundred twenty-seven patients utilized the EICU, representing approximately 1.8% of freestanding ED patients. Ambulance arrival occurred in 31.6% of all EICU patients. Median length of stay was 11.55 hours; this was significantly longer for patients requiring airborne isolation (25.60 versus 11.37 hours, P<0.0001 by Wilcoxon rank sum test). After stabilization and treatment, 39% of EICU patients had an improvement in their disposition status (P<0.0001 by Wilcoxon signed rank test); upon interhospital transfer, the absolute proportion of patients requiring ICU and SDU resources decreased from 37.8% to 27.1% and from 22.2% to 2.7%, respectively. CONCLUSIONS: An EICU attached to a freestanding ED achieved significant reductions in resource-intensive medical care. Flexible, adaptable care systems should be explored for implementation in disaster response. (Disaster Med Public Health Preparedness. 2016;10:496-502).

CONTEXT: Manganese-associated parkinsonism is well described in occupational settings, in chronic methcathinone users, and in patients receiving long-term total parenteral nutrition. We present a unique case of acute intravenous manganese poisoning with a systematic evaluation of hemodialysis efficacy. CASE DETAILS: A 52-year-old woman was inadvertently administered a single intravenous dose of 800 mg compounded manganese chloride at an outpatient chelation center. In an attempt to minimize central nervous system (CNS) manganese deposition, she underwent urgent hemodialysis followed by five days of therapy with calcium disodium EDTA (1 g/m2 over eight hours daily). Her initial whole blood manganese concentration, obtained six hours after exposure and prior to treatment, was 120 mcg/L (2.19 micromol/L); normal <5 mcg/L (< 0.09 micromol/L). Following the first four-hour hemodialysis session her blood manganese concentration decreased to 20 mcg/L (0.36 micromol/L). Despite the fall in her blood manganese concentration, analysis of dialysate revealed a total elimination of only 604 mcg (11 micromol) manganese ( approximately 1.4% of manganese burden). Although she remained asymptomatic, an MRI on hospital day two revealed T1 hyperintensities within the bilateral globus pallidi, consistent with manganese exposure. DISCUSSION: Manganese poisoning is associated with irreversible neurologic toxicity. Hemodialysis did not appear to significantly enhance elimination in this case of acute intravenous manganese toxicity, beyond supportive care and calcium disodium EDTA chelation.

OBJECTIVE: The emergency department (ED) of NYU Langone Medical Center was destroyed by Hurricane Sandy, contributing to a public health disaster in New York City. We evaluated hospital-based acute care provided through the establishment of an urgent care center with an associated ED-run observation service (EDOS) that operated in the absence of an ED during this disaster. METHODS: We conducted a retrospective cohort study of all patients placed in an EDOS following a visit to an urgent care center during the 18 months of ED closure. We reviewed diagnoses, clinical protocols, selection criteria, and performance metrics. RESULTS: Of 55,723 urgent care center visits, 15,498 patients were hospitalized, and 3167 of all hospitalized patients (20.4%) were placed in the EDOS. A total of 2660 EDOS patients (84%) were discharged from the EDOS. The 8 most frequently utilized clinical protocols accounted for 76% of the EDOS volume. CONCLUSIONS: A diverse group of patients presenting to an urgent care center following the destruction of an ED by natural disaster can be cared for in an EDOS, regardless of association with a physical ED. An urgent care center with an associated EDOS can be implemented to provide patient care in a disaster situation. This may be useful when existing ED or hospital resources are compromised. (Disaster Med Public Health Preparedness. 2016;page 1 of 6).