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Intraventricular conduction abnormalities are commonly seen on the electrocardiograms of patients in the emergency department population. The significance of such a finding can vary widely. When placed into clinical context, determination and description of an intraventricular conduction delay (IVCD) can assist in the management of a number of pathologiesDLdirectly cardiac and otherwise. The IVCDs discussed in this review include the unifascicular blocks (right bundle branch block [RBBB], left anterior fascicular block [LAFB], and left posterior fascicular block [LPFB]) and the bifascicular blocks (left bundle branch block, RBBB plus LAFB, and RBBB plus LPFB). After a review of these IVCDs, a simplified algorithm that will aid in the electrocardiographic diagnosis of these conduction abnormalities is presented. © 2009 Elsevier Inc. All rights reserved. [ABSTRACT FROM AUTHOR]

'Bath salts' are being increasingly used as drugs of abuse. These products have been found to contain a variety of compounds, including 3,4-methylenedioxypyrovalerone (MDPV). We present a case of a 25-year-old man who injected bath salts and acutely developed severe agitation, hyperthermia, and tachycardia. Despite aggressive early medical management, including dialysis, he progressed to multiorgan system failure, although he ultimately recovered after a prolonged hospital course. The only chemical substance detected on comprehensive toxicologic testing was MDPV, a synthetic cathinone analogue. According to our case, MDPV abuse may result in adverse multisystem organ effects, including rhabdomyolysis, cardiac injury, hepatic injury, and renal failure. It is unknown whether these end-organ effects were due to direct cellular toxicity induced by MDPV or a result of the patient's marked agitation and hyperthermia. Acute management should focus on the rapid identification of organ injury and appropriate supportive care. [ABSTRACT FROM AUTHOR]

Introduction: The black widow spider, Latrodectus mactans , stands out as one of the most medically significant arachnids due to its extensive geographic distribution in the United States and its ability to produce a potent neurotoxin, α-latrotoxin. This study aimed to describe the epidemiology of black widow spider exposures by month of exposure, geographic distribution, demographics, symptoms, treatment, and health system resource utilization between 2012 and 2022., Methods: This was a retrospective observational study using the US National Poison Data System, the data warehouse of the 55 US poison centers. A descriptive analysis of patient demographic data, month of exposure, clinical effects, level of healthcare received, and medical outcome was performed., Results: During the studied period, a total of 15,299 cases of Latrodectus spp exposures were reported to US poison centers. Exposures occurred with higher frequency in warm-weather states and during summer months. Almost half the cases were managed outside a healthcare facility (48.6%). Hospital admission was required for 10.0% of exposures. The most common therapies received were wound care (43.7%) and benzodiazepines (18.6%). Antivenom was administered in 3.4% (n=521) of exposures., Conclusions: Poison center data indicate that most black widow spider exposures result in minor consequences. Supportive care is the primary approach for black widow spider bites. Although antivenom use is infrequent, providers may seek administration guidance from toxicologists through local poison centers. This study underscores the pivotal role of poison centers in mitigating unnecessary healthcare visits and subsequent hospitalizations.

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., (Copyright © 2024 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

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.

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., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

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., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Moore et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

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., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest.

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.

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.

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.

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., Competing Interests: The authors declare no competing financial interest., (© 2022 The Authors. Published by American Chemical Society.)

The most common chemicals used in riot control agents are chlorobenzylidene malononitrile, chloroacetophenone, dibenz[b,f]-[1,4]-oxazepine, and oleoresin capsicum. They cause ocular, respiratory, and dermal effects usually within seconds to minutes of exposure, but delayed effects have been reported. In addition, the canisters containing these chemicals can cause traumatic injuries when launched as projectiles. Although most effects are mild, some may be serious, especially in those with preexisting respiratory disease. Treatment consists of removing the patient from the source of exposure, removing contaminated clothes, and copiously irrigating the affected areas with water., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2022 Elsevier Inc. All rights reserved.)

When evaluating a potentially poisoned patient, there is no substitute for a thorough history and physical examination. Clues from the examination are generally more likely to be helpful than a "shotgun" laboratory approach that involves indiscriminate testing of blood or urine for multiple agents. When used appropriately, diagnostic tests may be of help in the management of the intoxicated patient. When a specific toxin or even class of toxins is suspected, requesting qualitative or quantitative levels may be appropriate. The purpose of this review is to examine the role of common diagnostic tests in the evaluation of the poisoned patient., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2022 Elsevier Inc. All rights reserved.)

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 osmol gap in patient management., (Copyright © 2022 Elsevier Inc. All rights reserved.)

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.

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).

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., (Copyright © 2021. Published by Elsevier Inc.)

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., Competing Interests: Disclosure The authors do not have any commercial or financial conflicts of interest, and there are no funding sources for this article., (Copyright © 2021 Elsevier Inc. All rights reserved.)

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., (© The Author(s) 2021. Published by Oxford University Press.)

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.

Background: Buprenorphine prescriptions have increased dramatically within the United States, whereas methadone continues to be used widely. We investigated the trends and characteristics of buprenorphine and methadone exposures in the pediatric population., Methods: We identified pediatric exposures to buprenorphine and methadone using the National Poison Data System from 2013 to 2016. We descriptively assessed characteristics of the exposures. Trends in exposures were evaluated using generalized linear mixed models., Results: Pediatric buprenorphine exposures increased from 2013 (1097) to 2016 (1226) while methadone calls decreased (486 to 396). After adjusting for the random effects of the geographical region, the mean number of pediatric buprenorphine exposures (per 100,000 pediatric population) increased from 1.3 to 1.5 (P = .05). Conversely, the mean number of methadone exposures decreased from 0.6 to 0.4 (P = .03). Children aged ≤3 years constituted the highest percentage of both exposures. Unintentional exposures accounted for most of the buprenorphine (86.9%) and methadone (62.4%) exposures. Major clinical effects were demonstrated in 2.3% of buprenorphine exposures and were more frequent with methadone (13%). West Virginia and Maryland demonstrated the highest incidence of buprenorphine and methadone exposures, respectively., Conclusions: Pediatric buprenorphine exposures increased but demonstrated less severe effects compared to methadone exposures, which decreased during the study period., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Study Objective: The antivenom currently available for treatment of systemic black widow envenomation (latrodectism) is composed of equine whole immunoglobin. Although considered effective, it has been associated with anaphylaxis and 2 reported fatalities. We test the efficacy and safety of new equine antivenom composed of purified F(ab') 2 antibody fragments., Methods: A randomized, double-blind, placebo-controlled trial was conducted at 16 sites across the United States. Subjects aged 10 years or older with moderate to severe pain because of black widow spider envenomation received F(ab') 2 antivenom or placebo. The primary outcome measure was treatment failure, which was defined as failure to achieve and maintain clinically significant reduction in pain for 48 hours posttreatment. Secondary measures of pain intensity differences and summed pain intensity difference were computed. Adverse events were recorded., Results: Sixty patients were treated (29 antivenom and 31 placebo). The mean age was 39 years and 68% were male. There were 15 treatment failures in the antivenom group and 24 in the placebo group (P=.019). Differences in pain intensity difference between groups were lower at each postbaseline point, and the mean summed pain intensity difference was greater for the antivenom group (difference 2,133; 95% confidence interval 177 to 4,090). No deaths or serious drug-related adverse events were detected., Conclusion: The F(ab') 2 antivenom met the predefined primary outcome of reduced treatment failures. Secondary outcomes of pain intensity difference and summed pain intensity difference also supported efficacy. The rate of symptom improvement in the placebo group was higher than expected, which may be related to enrollment criteria or placebo effect., (Copyright © 2019 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2019 Elsevier B.V. All rights reserved.)

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.

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., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: This study aimed to develop a predictive model to quantify the risk of student harmful drinking associated with emergency department (ED) visits and/or campus-wide incidents reported to campus authorities in a U.S. public university., Methods: Six-year (2010/11-2015/16) student enrollment data were linked to subsequent harmful drinking events defined as either alcohol intoxication associated with ED visits or alcohol-related incidents reported to authorities within 1 year following the annual (index) enrollment. Multivariable logistic regression analysis was used to develop a risk predictive model based on the first 3-year student cohort (n = 93,289), which was then validated in the following 3-year student cohort (n = 85,876)., Results: A total of 2609 students in the derivation cohort and 2617 students in the validation cohort had at least 1 harmful drinking event within 1 year following the index enrollment, providing an incidence of 2.8% and 3.1%, respectively. Student demographics (gender, age, ethnicity, parental tax dependency), academic level, Greek life member, transfer students, first-time enrolled students, having been diagnosed with depression or injury, and violence involvement were statistically significant predictors. C-statistics of the model were 0.86 in both cohorts, with excellent calibration and no evidence of over- or under-prediction observed from calibration plots., Conclusions: By linking routinely collected student data, a robust risk predictive model was developed and validated to quantify absolute risk of harmful drinking for every student. This model can provide a useful tool for clinicians or health educators to make real time decision to plan target interventions for students at elevated risk., (Copyright © 2019. Published by Elsevier B.V.)

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., (© 2018 Society for the Study of Addiction.)

Objective: The aim of this systematic review was to identify isolated acute cyanide poison cases and to identify reported signs, symptoms, and laboratory findings., Methods: We searched MEDLINE, Cochrane Reviews, and Web of Science case reports and series using a number of MeSH descriptors pertaining to cyanide, toxicity, and poisonings. We excluded studies on plants, laboratory analyses, smoke inhalation poisonings, animals as well as non-English language articles and those in which data were not available. Data extracted included demographics, exposure characteristics, acute signs/symptoms, and medical management and outcome., Results: From the initial 2976 articles retrieved, 65 articles (52 case reports, 13 case series) met inclusion criteria and described 102 patients. Most patients were unresponsive (78%), hypotensive (54%), or had respiratory failure (73%); other signs and symptoms included cardiac arrest (20%), seizures (20%), cyanosis (15%), cherry red skin (11%), and had an odor present (15%). Medical management included cyanide antidote kit (20%), sodium thiosulfate (40%), and hydroxocobalamin (29%). The majority of cases (66%) required intubation with mechanical ventilation and a substantial number (39%) developed refractory hypotension requiring vasopressor support., Conclusions: Contrary to general reviews published on cyanide toxicity, reports of cherry red skin and bitter almond odor were rare among published cyanide cases. Consistent with other studies, metabolic acidosis with significant lactic acidosis were the laboratory values consistently associated with cyanide toxicity. Healthcare providers may overlook cyanide toxicity in the differential diagnosis, if certain expected characteristics, such as the odor of almonds or a cherry red color of the skin are absent on physical examination.

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., (Copyright © 2018 Elsevier B.V. All rights reserved.)

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., (Copyright © 2017 Elsevier B.V. All rights reserved.)

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., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Study Objective: Loperamide abuse has been increasing in the United States as a potential alternative to manage opioid withdrawal symptoms or to achieve euphoric effects of opioid use. In June 2016, the Food and Drug Administration warned health care providers and the general public about potential serious adverse outcomes, including cardiac dysrhythmias and death. The purpose of this study is to determine recent trends in intentional loperamide abuse and misuse, reported clinical effects and management, and medical outcomes as reported to poison centers across the United States., Methods: Loperamide exposures reported to the National Poison Data System indicating intentional misuse, abuse, and suspected suicide between January 1, 2010, and December 31, 2015, were assessed. Demographic and temporal trends, as well as reported clinical effects, medical management, and health outcomes, were analyzed., Results: There was a 91% increase in reported exposures from 2010 to 2015, of which half were single-agent loperamide use only. Loperamide exposures reported to the National Poison Data System increased at approximately 38 cases per year (95% confidence interval [CI] 32.5 to 42.9; P<0.0001). Fifteen deaths were reported during this time frame, of which 8 involved single-agent loperamide abuse., Conclusion: Loperamide abuse and misuse are projected to increase in the absence of any methods to reduce exposure or curb abuse. Health care providers should consider the potential for loperamide toxicity when managing patients with opioidlike toxicity., (Copyright © 2016 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Lyme disease is a multisystem tickborne illness caused by the spirochete Borrelia burgdorferi and is the most common vectorborne disease in the United States. Prognosis after initiation of appropriate antibiotic therapy is typically good if treated early. Wilderness providers caring for patients who live in or travel to high-incidence Lyme disease areas should be aware of the basic biology, epidemiology, clinical manifestations, and treatment of Lyme disease., (Published by Elsevier Inc.)

Objective: The purpose of this study was to characterize the epidemiological trends associated with substances used in intentional exposures among children while on school property reported to the U.S. National Poison Data System (NPDS)., Materials and Methods: NPDS was queried for intentional (abuse, misuse, suspected suicide, and unknown intentional) exposures reported to occur on school property between calendar years 2004 and 2013. Records were restricted to children 6-18 years of age. Demographic, exposure, and clinical characteristics were assessed., Results: A total of 56,882 substances were intentionally used on school property by 50,379 children, of which 39.8% were females (n = 20,070), 57.7% were males (n = 29,084), and 2.4% were unknown gender (n = 1,225). The most frequent pharmaceutical exposures reported included sedatives (n = 4,096; 8.1%), analgesics (n = 4,022; 8.0%), and cough and cold preparations (n = 3,529; 7.0%). The majority of exposures were managed on site (n = 21,464; 42.6%), followed by care at a healthcare facility (n = 20,048; 39.7%). Serious outcomes (moderate or major effects and death) accounted for nine percent of all reported exposures. Compared to reference groups, female gender, teenagers 17-18 years, and pharmaceutical substances (Prevalence Ratios = 4.6, 9.4, and 9.9, respectively) were associated with suspected suicides when compared with other intentional exposures., Conclusions: Along with other national data about behaviors in the adolescent and teenage population, additional trends in risky behavior may be gleaned by surveillance through poison centers. With over 5,000 annual reports to the poison centers about intentional exposures on school property, school personnel and parents/guardians must be vigilant about the range of pharmaceutical and non-pharmaceutical substances that are used for abuse, misuse, or suicide.