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Background: Patients with ongoing symptoms after non-operative treatment of lateral epicondylosis are usually treated with surgical release. Platelet-rich plasma injection is an alternative treatment option. This study aims to determine whether there is a difference in outcome from platelet-rich plasma injection or surgical release for refractory tennis elbow. Method: Eighty-one patients with a diagnosis of tennis elbow for a minimum of six months, treated with previous steroid injection and a minimum visual analogue scale pain score of 50/100 were randomised to open surgery release (41 patients) or leucocyte rich platelet-rich plasma (L-PRP) (40 patients). Patients completed the Patient-Rated Tennis Elbow Evaluation and Disability of the Arm Shoulder and Hand at baseline, 1.5, 3, 6 and 12 months post-intervention. The primary endpoint was change in Patient-Rated Tennis Elbow Evaluation pain score at 12 months. Results: Fifty-two patients completed final follow-up. Functional and pain scores improved in both groups. No differences in functional improvements were found but greater improvements in Patient-Rated Tennis Elbow Evaluation pain scores were seen after surgery. Thirteen patients crossed over from platelet-rich plasma to surgery within 12 months, and one surgical patient underwent a platelet-rich plasma injection. Conclusion: L-PRP and surgery produce equivalent functional outcome but surgery may result in lower pain scores at 12 months. Seventy per cent of patients treated with platelet-rich plasma avoided surgical intervention. [ABSTRACT FROM AUTHOR]

Study objective Metformin is known to cause potentially fatal metabolic acidosis with an increased lactate level in both overdose and therapeutic use. No association between mortality and serum pH, lactate level, or metformin concentrations, though intuitive, has yet been described. This systematic literature review is designed to evaluate the association between mortality and serum pH, lactate level, and metformin concentrations in acute metformin overdose. Methods We reviewed the literature by using the MEDLINE, EMBASE, CINAHL, and TOXNET databases for cases of metformin overdose with documented mortality data and values of serum pH, lactate level, and metformin concentrations. When available, patient age, patient sex, and whether patients received intravenous sodium bicarbonate therapy or hemodialysis were also analyzed. Cases meeting inclusion criteria were analyzed to determine whether a difference in distribution of nadir serum pH, peak serum lactate level, or peak serum metformin concentrations existed between overdose survivors and nonsurvivors. Results We identified 10 articles that had 1 or more cases meeting our inclusion criteria. In total, there were 22 cases of metformin overdose (5/22 died) that met inclusion criteria. No intentional overdose patients died whose serum pH nadir was greater than 6.9, maximum lactate concentration less than 25 mol/L, or maximum metformin concentration less than 50 ug/mL (therapeutic range 1 to 2 ug/mL). Intentional overdose patients with a nadir serum pH less than 6.9 had 83% mortality (5/6), those with lactate concentration greater than 25 mmol/L had 83% mortality (5/6), and those with metformin concentration greater than 50 microg/mL had 38% mortality (5/12). Nadir serum pH and peak serum lactate and metformin concentration distributions in survivors and nonsurvivors revealed that survivors had a median nadir pH of 7.30, interquartile range (IQR) 7.22, 7.36; nonsurvivors, a median nadir pH of 6.71, IQR 6.71, 6.73; survivors, a median peak lactate level of 10.8 mmol/L, IQR 4.2, 12.9; nonsurvivors, a median peak lactate level of 35.0 mmol/L, IQR 33.3, 39.0; survivors, a median peak metformin level of 42 ug/mL, IQR 6.6, 67.6; and nonsurvivors, a median peak metformin level of 110 ug/mL, IQR 110, 110. Conclusion No cases of acute metformin overdose meeting the study's inclusion criteria were found in which patients with a nadir serum pH greater than 6.9, peak serum lactate concentrations less than 25 mmol/L, or peak serum metformin concentrations less than 50 ug/mL died. Patients with acute metformin overdose who died had much lower serum pH nadirs and much higher peak serum lactate and metformin concentrations than those who survived. [ABSTRACT FROM AUTHOR]

Introduction: The Extracorporeal Treatments in Poisoning (EXTRIP) workgroup suggests hemodialysis in severe lithium poisoning if specific criteria are met. One criterion is if the expected time to obtain a lithium concentration <1.0 mEq/L with optimal management is >36 h. There are a lack of data regarding which patient characteristics are associated with the rate at which patients achieve a lithium concentration <1.0 mEq/L., Methods: We conducted a retrospective chart review analyzing hospital electronic medical records. Inclusion criteria consisted of a lithium concentration >1.2 mEq/L during hospitalization. We excluded patients who received extracorporeal treatment before 36 h elapsed from time of initial lithium concentration >1.2 mEq/L. The primary analysis consisted of a Cox regression and a secondary analysis evaluated the nomogram method described by Buckley and colleagues for predicting prolonged supratherapeutic lithium concentration., Results: One hundred and one patients were included in the study. The median time to reach a lithium concentration <1.0 mEq/L was 42.5 h (IQR: 33.8-51.1). Older patients, patients taking a thiazide, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, patients with a higher initial lithium concentration, and patients with higher sodium concentrations achieved a lithium concentration <1 mEq/L at a slower rate. For the nomogram analysis, sensitivity (61.5%) and specificity (54.5%) were moderate, the positive predictive value (16.7%) was poor, and the negative predictive value (90.6%) was excellent., Discussion: The results from our primary analysis suggest that identifying higher serum sodium concentration and use of certain antihypertensives that decrease glomerular filtration rate as predictors of an increased time to reach a therapeutic lithium concentration may help identify patients who meet the Extracorporeal Treatments in Poisoning criteria for hemodialysis. The nomogram method performed similarly to prior validation studies., Conclusions: In this retrospective chart review of patients with supratherapeutic lithium concentrations, we identified several risk factors for prolonged supratherapeutic lithium concentrations.

Molten salts have a significant potential for use as next-generation nuclear reactor coolants and in pyroprocessing for the recycling of used nuclear fuel. However, the molten salt composition needs to be known at all times, and high temperatures and intense ionizing radiation pose challenges for the monitoring instrumentation. Although the technique of laser-induced breakdown spectroscopy (LIBS) has been studied for in situ measurements of molten salts, trials to improve its monitoring accuracy using chemometrics are lacking. In this study, a data fusion technique using the LIBS optical and laser-induced acoustic (LIA) signals was investigated to enhance the measurement accuracy for molten salt monitoring. Prediction models were constructed using the partial least-squares method, and the variable importance in projection scores was analyzed to evaluate the effect of incorporating the LIA signal into the analysis. This study investigates rare earth elements Eu, Er, and Pr found not only in nuclear but also in other settings such as laser and magnetic materials. The analysis of LIBS data without data fusion resulted in a root-mean-square error of prediction (RMSEP) of 0.0774-0.0913 wt %, whereas the prediction model using data fusion led to approximately 18-40% enhanced RMSEP (0.0461-0.0679 wt %). The results suggest that fusing the LIBS data with the simultaneously recorded LIA data can improve the monitoring accuracy of rare earth element composition in molten salts.

Introduction: Oral potassium poisoning can be life-threatening. The study aimed to describe patterns of oral potassium poisoning in adult and pediatric populations and characterize its clinical presentation and management as reported by United States poison centers., Methods: This is a retrospective review of the National Poison Data System from 1 January 2010 through 30 June 2021. We descriptively analyzed cases involving single substance, oral potassium salts. In a second step, we requested a subset of case-specific narratives for cases that resulted in major outcome or death, as well as cases where patients received any of the following therapies: whole bowel irrigation, sodium bicarbonate, calcium, insulin or hemodialysis. We classified hyperkalemia by expected toxicity: mild (peak potassium concentration <6.5 mEq/L), moderate (peak potassium concentration 6.5 to <8 mEq/L) or severe (peak potassium concentration ≥ 8mEq/L)., Results: The National Poison Data System included 1,820 cases, 52.3 percent being adults. Among adult cases, 20% ( n  = 189) resulted in a moderate effect, major effect or death. Among pediatric cases aged <10 years, all exposures were unintentional. Analysis of 49 case narratives showed a median peak potassium concentration of 7.1 mEq/L (interquartile range 5.4-8.6) and a moderate correlation with the dose ingested (r = 0.66). Severe hyperkalemia was associated with QRS complex widening ( P  < 0.001), peaked T-waves ( P  = 0.001), and neurological symptoms ( P  = 0.04). Whole bowel irrigation was associated with mild hyperkalemia ( P  = 0.011), and hemodialysis was associated with severe hyperkalemia ( P  < 0.001)., Discussion: Analysis of data showed that therapy to promote intracellular shift of potassium is the mainstay of management of oral potassium poisoning, followed by hemodialysis., Limitations: Poison center data are susceptible to reporting bias. National Poison Data System data are affected by completeness and accuracy of reporting from health care providers and the lay public., Conclusions: Single substance, oral potassium poisoning, reported to United States poison centers, is mostly unintentional and rarely results in hyperkalemia.

Increased absorption of optical materials arising from exposure to ionizing radiation must be accounted for to accurately analyze laser-induced breakdown spectroscopy (LIBS) data retrieved from high-radiation environments. We evaluate this effect on two examples that mimic the diagnostics placed within novel nuclear reactor designs. The analysis is performed on LIBS data measured with 1% Xe gas in an ambient He environment and 1% Eu in a molten LiCl-KCl matrix, along with the measured optical absorption from the gamma- and neutron-irradiated low-OH fused silica and sapphire glasses. Significant changes in the number of laser shots required to reach a 3σ detection level are observed for the Eu data, increasing by two orders of magnitude after exposure to a 1.7 × 10 17 n/cm 2 neutron fluence. For all cases examined, the spectral dependence of absorption results in the introduction of systematic errors. Moreover, if lines from different spectral regions are used to create Boltzmann plots, this attenuation leads to statistically significant changes in the temperatures calculated from the Xe II lines and Eu II lines, lowering them from 8000 ± 610 K to 6900 ± 810 K and from 15,800 ± 400 K to 7200 ± 800 K, respectively, for exposure to the 1.7 × 10 17 n/cm 2 fluence. The temperature range required for a 95% confidence interval for the calculated temperature is also broadened. In the case of measuring the Xe spectrum, these effects may be mitigated using only the longer-wavelength spectral region, where radiation attenuation is relatively small, or through analysis using the iterative Saha-Boltzmann method.

Introduction: The Veratrum genus is composed of plants containing a diverse set of steroidal alkaloids. Veratrum plant material has been utilized for centuries as herbal medicines, however the alkaloids have such a low therapeutic index that they are not used in modern medicine. Here we report an incident of inadvertent ingestion of V. parviflorum by hikers in Georgia that allowed detection, and in several instances identification of alkaloids from the plant, and correlated their presence within patient blood and breast milk specimens., Case History: Eight patients, three male and five female, presented in the spring of 2020 and 2021 with symptoms requiring emergent medical attention after ingestion of Veratrum parviflorum. All patients believed the plants to be a local native species of wild leek, Allium tricoccum , locally known as ramps. Plants were identified using photographs as well as fresh and cooked plant material provided by patients, in consultation with botanists at the University of Georgia Herbarium. Written consent was obtained from all patients for collection of blood and breast milk specimens for laboratory identification of Veratrum alkaloids., Methods: V. parviflorum plant material, and patient serum and breast milk were analyzed by high performance liquid chromatography-quadrupole time-of-flight mass spectrometry (HPLC-QTOF) to identify steroidal alkaloids., Results: The V. parviflorum extract was confirmed to contain cyclopamine, veratramine, jervine, and muldamine. Two out of the eight patients had detectable concentrations of Veratrum alkaloids. Of the alkaloids identified in the plant, cyclopamine and jervine were detected within patient serum, and cyclopamine and veratramine were observed to be present in breast milk., Discussion: Toxicity resulting from Veratrum steroidal alkaloids has primarily been reported from V. album and V. viride . This is the second report of V. parviflorum poisoning. The present work reports for the first time the presence of muldamine and jervine within V. parviflorum . This work provides the first instance of identification of Veratrum alkaloids in breast milk. Thus, the findings presented herein add to literature record causative agents contributing to the toxicity of V. parviflorum when ingested and potential for secondary poisoning through breastfeeding., Conclusion: V. parviflorum toxicity was observed to cause nausea, vomiting, hypotension, bradycardia, abdominal pain, light-headedness, blurred vision, and tingling in the arms. Patients experiencing mild symptoms improved with supportive care, IV fluids, and antiemetics, but hemodynamically unstable patients required atropine and vasopressors. This study demonstrated that more lipophilic Veratrum alkaloids can be passed along in breast milk, which suggests additional precautions may be critical to limit further poisonings.

Background: Historically, the first step in treating cyanide (CN - ) toxicity utilized antidotes to induce methemoglobinemia. This is concerning in patients who are already hypoxemic or have elevated carboxyhemoglobin. Hydroxocobalamin (OHCbl) is now the first-line antidote for CN - toxicity and is not known to induce methemoglobinemia. We observed elevated methemoglobin (MetHb) levels in several patients treated with OHCbl and sought to investigate the incidence of MetHb formation following administration of OHCbl., Methods: Chart review: A single-center, retrospective case series of patients who received 5 or 10 g of hydroxocobalamin from 01/01/2011 through 04/30/2019. Data was analyzed using descriptive statistics. In-vitro study: Discarded blood was separated into whole blood and plasma samples. OHCbl and normal saline was added to reach 0×, 1×, 2×, and 4× peak therapeutic concentrations and analyzed at times 0, 2, and 4 h after administration., Results: Chart review : Twenty-seven cases of OHCbl administration were identified. The median age was 53 years (IQR 38 - 64) and 20 (74.1%) were male. Exposure to a house fire or smoke inhalation was the reason for OHCbl administration in 21 (77.8%) patients. Five (18.5%) patients received 10 g of OHCbl while the rest received 5 g. Six (22.2%) patients developed methemoglobinemia, all after 5 g OHCbl administration; four had been exposed to fire and smoke, two received the medication for severe acidosis of unknown etiology not related to fire or smoke. The median peak level was 7.1% (IQR 2.2 - 16.4%) at a median time of 11.4 h post-administration. Two patients received methylene blue (MB), neither responded. Death occurred in 17 (63%) cases. In-vitro study: We observed a dose dependent elevation in total hemoglobin but did not detect any increase in MetHb., Conclusion: We observed a noteworthy temporal association between the formation of methemoglobinemia and the administration of hydroxocobalamin. This does not appear to be an artifact of the CO-oximeters. This could have profound implications for patients who are already hypoxemic or have impaired oxygen carrying capacity from carboxyhemoglobin.

Purpose: To investigate the effect of bursal acromial reconstruction (BAR) using an acellular dermal allograft on glenohumeral joint kinematics including maximum abduction angle, glenohumeral superior translation, cumulative deltoid force, and subacromial contact pressure., Methods: In this dynamic biomechanical cadaveric shoulder study, 8 fresh-frozen cadaveric shoulders (age 53.4 ± 14.2 years, mean ± standard deviation) were tested using a dynamic shoulder testing system. Maximum abduction angle (MAA), glenohumeral superior translation (ghST), maximum cumulative deltoid force (cDF), and subacromial peak contact pressure (sCP) were compared across 3 conditions: (1) intact shoulder; (2) massive retracted irreparable posterosuperior rotator cuff tear (psRCT) according to Patte III; and (3) BAR. Additionally, humeral head containment was measured using contact pressure., Results: Compared with the simulated psRCT, BAR significantly increased mean MAA and significantly decreased ghST (P < .001, respectively) and cDF (P = .017) Additionally, BAR was found to significantly decrease sCP compared with psRCT (P = .024)., Conclusion: In a dynamic biomechanical cadaveric shoulder simulator, resurfacing the undersurface of the acromion using the BAR technique leads to significantly improved ghST, MAA, cDF, and sCP compared with the irreparable rotator cuff tear., Clinical Relevance: With the BAR technique, native humeral containment may be restored, which can potentially delay progressive subacromial and glenoidal abrasive wear and improve overall shoulder function. As such, the proposed BAR technique can be considered as a technically feasible and potentially cost- and timesaving procedure, as no bone anchors are needed, glenoidal or humeral side graft ruptures can be avoided, and postoperative rehabilitation can be started immediately. However, future clinical studies are needed., (Copyright © 2021 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

The use of optical instrumentation in advanced nuclear fission systems, such as molten salt reactors, liquid metal-cooled reactors, and high-temperature gas-cooled reactors, has the potential to enhance reactor safety and economic performance through in situ and online measurement of reactor conditions. Selection of suitable optical components, such as optical windows and fibers, is essential for operation of optical instrumentation in intense radioactive and thermal environments inherent to nuclear reactor systems. We present the development and performance of a self-contained and mobile post-irradiation examination system for rapid characterization of the optical properties of materials. The instrument combines linear absorption and nanosecond Z-scan modules in a compact, relocatable design. The system mobility allows for the evaluation of optical samples at the site of irradiation, minimizing the delay between extraction from the irradiation site and optical characterization. This provides nearly real-time information on the material performance under simultaneous irradiation and thermal annealing, simulating the relevant conditions for the use of those components in nuclear power systems.

Background: Despite its preventable nature, poisoning remains one of the leading causes of morbidity and mortality in the pediatric population. In Lebanon, this population is poorly studied and there is no poison center to which healthcare providers and the public can refer in case of toxicological exposure, leading to unnecessary Emergency Department (ED) visits. This study describes the pediatric toxicological exposures seen at the largest tertiary care center in Lebanon. It also evaluates the appropriateness of ED visits among confirmed or suspected toxicological exposures in children, in order to assess the role of a national poison center in reducing unnecessary ED visits., Methods: This is a secondary analysis of a database for a telephonic medical toxicology service at the American University of Beirut Medical Center, the largest tertiary care center in Lebanon. Data relating to all pediatric patients aged 0-19 years of age were entered into the database by the medical toxicology team. The cases were independently reviewed by 2 medical toxicologists for the adequacy of referral to the ED and performance of invasive procedures., Results: Two hundred and nine exposures were recorded between 15 April 2015 and 31 December 2019, of which 53.1% were females. Children aged less than 5 years were involved in 67.0% of cases while adolescents aged 13-19 years were involved in 21.1%. The most commonly involved substances were analgesics (14.8%) and cardiovascular drugs (10.0%). The majority had no (59.3%) or minor (26.3%) effects and were treated and discharged home (67.5%). More than a third of ED visits were deemed unnecessary by the toxicologists (Kappa = 0.705), and when including only unintentional cases, around 45% of the ED visits were deemed unnecessary (Kappa = 0.677)., Conclusion: Our data show that 37% of all pediatric poisoning ED visits and 45% of ED visits due to unintentional pediatric poisonings were unnecessary. Additionally, more often than not lavage suctions were done unnecessarily. Future research investigating the possibility of preventing unnecessary visits by establishing a national poison center is needed.

Poisoning and envenomation are a global health problem for which the mortality burden is shouldered heavily by middle- and low-income countries that often lack poison prevention programs and medical toxicology expertise. Although telehealth or teleconsult services have been used to bridge the expertise gap between countries for multiple specialties, the use of medical toxicology teleconsult services across borders has been limited. We aim to describe the use of a United States-based medical toxicology teleconsult service to support patient care at a hospital in a middle-income country that lacks this expertise. This report outlines the logistics involved in setting up such a service, including the challenges and opportunities that emerged from establishing medical toxicology teleconsult service in a low-resource setting.

Background: Cyanide (CN) toxicity commonly occurs during enclosed-space fires. Historically, the first step in treating CN toxicity utilized amyl nitrite and sodium nitrite to induce methemoglobinemia, which can be dangerous in this population. Hydroxocobalamin (OHCob), which binds to CN to form the nontoxic metabolite cyanocobalamin, is now the first-line antidote for CN toxicity, and has the advantage of not inducing methemoglobinemia., Case Report: A 62-year-old man presented to the Emergency Department (ED) after a house fire. He was intubated for respiratory distress and hypoxia with an initial carboxyhemoglobin of 1.3%, methemoglobin 0.3%, and anion gap 19. Eleven hours after presentation, his serum lactic acid was 9 mmol/L. Given his continued deterioration, 14 h after arrival he received OHCob 5 g i.v. for presumed CN toxicity. Methemoglobin concentration 4 min prior to OHCob administration was 0.7%, and 2 h after administration was 4.2%. This subsequently increased to 14.3% (16 h after OHCob administration) and peaked at 16.3% (47 h after OHCob administration), at which time he was administered a dose of methylene blue 50 mg i.v., 60 h after ED arrival. His methemoglobin concentrations fluctuated until a consistent downward trend starting at 92 h from ED arrival. He continued to deteriorate and expired on hospital day 5 with a methemoglobin concentration of approximately 6.0%. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: CN toxicity requires immediate recognition and treatment. The antidote, OHCob, is believed to not induce methemoglobinemia. However, this potential side effect must be considered by emergency physicians when treating suspected CN toxicity, especially if the patient does not improve after antidotal therapy., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Partial articular supraspinatus tendon avulsion (PASTA) tears are common. However, there is no consensus on the optimal surgical technique for the management of grade 3 tears (>50%). The authors report a retrospective consecutive case series of 64 patients with grade 3 PASTA lesions. The patients were treated by 2 surgeons from 2 centers with the same transtendon repair technique and implant system. The preoperative Oxford Shoulder Score (OSS) was compared with the postoperative OSS at final follow-up (mean, 28 months). Significant improvement in mean OSS occurred from 19.2 (SD, 7.5) preoperatively to 39.8 (SD, 7.8) postoperatively (P=.0001), and patient satisfaction rates were high (88%). The authors believe that transtendon repair of PASTA lesions of 50% or more is beneficial. High-quality randomized controlled trials are required to compare the benefit of repair vs debridement alone. [Orthopedics. 2020;43(6):e533-e537.]., (Copyright 2020, SLACK Incorporated.)

Introduction: This study aims to describe the epidemiology of toxicological exposures reported to a telephonic medical toxicology service at a tertiary care center in Lebanon during a 46-months period. Methods: This study is a secondary analysis of a database for a telephonic medical toxicology service at a tertiary care center in Lebanon. Clinical information from all pediatric and adult patients, presenting with intentional or unintentional toxicological exposure, was entered into the database by the medical toxicology team. Results: Four hundred and seventy-seven exposures were recorded from 1 March 2015 to 31 December 2018. Female patients were involved in 60.2% of cases. Children less than 5 years old constituted 23.5% of cases and adults aged 20-49 constituted 48.6%. Up to 51.6% of cases were intentional, with 37.7% resulting from suicidal attempts. The majority of patients displayed no effects (33.1%) or minor effects (39.2%). Almost half of patients were treated and discharged from the Emergency Department (ED) without further hospitalization, and another 18.9% of patients left the ED against medical advice. The most common pharmaceutical agents involved were sedative/hypnotics/antipsychotics (14.7%), analgesics (12.6%) and antidepressants (11.3%). The most common non-pharmaceutical agents involved were household cleaning substances (8.0%), pesticides (5.2%) and bites and envenomations (3.8%). Conclusions: The results of this study suggest that sedative/hypnotics/antipsychotics, analgesics, antidepressants and household cleaning substances are the most common agents involved. Adult women and children ≤5 years old constitute a large portion of patients with toxicological exposures. Prevention strategies and policies should be implemented to mitigate these hazards.

Irreparable massive cuff tears in young patients pose a difficult problem for shoulder surgeons. Arthroscopic superior capsular reconstruction has shown promise in recent years in the treatment of this challenging patient population. The majority of the literature is limited to surgical techniques. The authors present the 2-year clinical outcomes of 25 patients undergoing arthroscopic superior capsular reconstruction with dermal allograft from a single center. The Oxford Shoulder Score and range of motion were assessed preoperatively and then at 3 to 6 months, 1 year, and 2 years following surgery. Patient satisfaction was recorded at final follow-up. Magnetic resonance imaging was performed at 3 months postoperatively to assess graft integrity. All patients were available at 1-year follow-up, and 23 were available at 2 years. The mean Oxford Shoulder Score improved by a minimum of 10 points at all time points compared with preoperatively. The mean forward flexion and abduction improved by 20° and external rotation by 7°. Revision to reverse shoulder arthroplasty was seen in 3 patients (12%). Graft failure was seen in 4 patients (16%). Overall, 20 patients had successful outcomes at 1 year (80%) and 18 patients had successful outcomes at 2 years (72%). Superior capsular reconstruction offers a safe and effective short-term bridging option for young patients with irreparable supraspinatus tears in the absence of glenohumeral arthritis. However, long-term outcome studies are required to evaluate the true clinical effectiveness and failure rates. [Orthopedics. 2020;43(4):215-220.]., (Copyright 2020, SLACK Incorporated.)

Objectives: Weaning protocols establish readiness-to-wean criteria to determine the opportune moment to conduct a spontaneous breathing trial. Weaning protocols have not been widely adopted or evaluated in ICUs in low- and middle-income countries. We sought to compare clinical outcomes between participants whose weaning trials were retrospectively determined to have been premature, opportune, or delayed based on when they met readiness-to-wean criteria., Design: Prospective, multicenter observational study., Setting: Five medical ICUs in four public hospitals in Lima, Perú., Subjects: Adults with acute respiratory failure and at least 24 hours of invasive mechanical ventilation (n = 1,657)., Interventions: None., Measurements and Main Results: We established six readiness-to-wean criteria and retrospectively categorized our sample into three weaning groups: 1) premature: if the weaning trial took place before fulfilling all criteria, 2) opportune: if the weaning trial took place within 24 hours after fulfilling the criteria, and 3) delayed: if the weaning trial took place over 24 hours after fulfilling criteria. We compared 90-day mortality, ventilator-free days, ICU-free days, and hospital-free days between premature, opportune, and delayed weaning groups. In our sample, 761 participants (60.8%) were classified as having a premature weaning trial, 196 underwent opportune weaning (15.7%), and 295 experienced delayed weaning (23.6%). There was no significant difference in 90-day mortality between the groups. Both the premature and delayed weaning groups had poorer clinical outcomes with fewer ventilator-free days (-2.18, p = 0.008) and (-3.49, p < 0.001), ICU-free days (-2.25, p = 0.001) and (-3.72, p < 0.001), and hospital-free days (-2.76, p = 0.044) and (-4.53, p = 0.004), respectively, compared with the opportune weaning group., Conclusions: Better clinical outcomes occur with opportune weaning compared with premature and delayed weaning. If readiness-to-wean criteria can be applied in resource-limited settings, it may improve ICU outcomes associated with opportune weaning.

Objective: To identify types of containers from which young children accessed solid dose medications (SDMs) during unsupervised medication exposures and the intended recipients of the medications to advance prevention., Study Design: From February to September 2017, 5 US poison centers enrolled individuals calling about unsupervised solid dose medication exposures by children ≤5 years. Study participants answered contextually directed questions about exposure circumstances., Results: Sixty-two percent of eligible callers participated. Among 4496 participants, 71.6% of SDM exposures involved children aged ≤2 years; 33.8% involved only prescription medications, 32.8% involved only over-the-counter (OTC) products that require child-resistant packaging, and 29.9% involved ≥1 OTC product that does not require child-resistant packaging. More than one-half of exposures (51.5%) involving prescription medications involved children accessing medications that had previously been removed from original packaging, compared with 20.8% of exposures involving OTC products (aOR, 3.39; 95% CI, 2.87-4.00). Attention deficit hyperactivity disorder medications (49.3%) and opioids (42.6%) were often not in any container when accessed; anticonvulsants (41.1%), hypoglycemic agents (33.8%), and cardiovascular/antithrombotic agents (30.8%) were often transferred to alternate containers. Grandparents' medications were involved in 30.7% of prescription medication exposures, but only 7.8% of OTC product exposures (aOR, 3.99; 95% CI, 3.26-4.87)., Conclusions: Efforts to reduce pediatric SDM exposures should also address exposures in which adults, rather than children, remove medications from child-resistant packaging. Packaging/storage innovations designed to encourage adults to keep products within child-resistant packaging and specific educational messages could be targeted based on common exposure circumstances, medication classes, and medication intended recipients., (Published by Elsevier Inc.)

Background: Individuals who have tested positive for cocaine have claimed that lidocaine, or its primary metabolite, norlidocaine (monoethylglycinexylidide (MEGX)), have caused false positive results for the cocaine metabolite benzoylecgonine (BE) on urinary immunoassay testing., Objective: The goal of the study was to determine if lidocaine exposure from routine medical procedures can result in false positives on a commercially available cocaine immunoassay urine drug screen (UDS)., Methods: We performed a cross-sectional observational study of patients receiving lidocaine as part of their regular care. Standard immunoassay drug screens and confirmatory liquid chromatography-mass spectrometry (LC-MS) were performed on all urine samples to assess for MEGX and BE., Results: In total, 168 subjects were enrolled; 121 samples positive for lidocaine were ultimately included for analysis. One hundred fourteen of the 121 were also positive for MEGX. None of the 121 were positive for cocaine/BE on the UDS (95% CI), 0-3.7% for the full sample and 0-3.9% for the 114 who tested positive for MEGX., Conclusion: The present study found no evidence that lidocaine or norlidocaine are capable of producing false positive results on standard cocaine urine immunoassays.

Background: The Emergency Department (ED) frequently treats patients with drug overdoses and is an important resource for individuals with opioid use disorder who are seeking treatment. Initiating medication-assisted treatment (MAT) in the ED seems to be an effective way to link patients with opioid use disorder (OUD) to treatment programs. There is ongoing discussion on the best approach to MAT in the ED setting., Objective: Describe a new model for managing OUD in the ED., Method: Information was obtained retrospectively from the electronic medical records of patients seen in a large county tertiary care center's Clinical Decision Unit (CDU) for OUD between September 1, 2017 and February 6, 2018. Data were summarized descriptively., Results: There were 18 different patients placed in the CDU during the study period. Ninety-five percent were induced with buprenorphine-naloxone in the CDU. The median initial Clinical Opioid Withdrawal Scale score at the time of induction was 10. The median total dose of buprenorphine-naloxone that was administered was 8/2 mg. The median amount of time spent in the CDU and ED combined was 23 h. Approximately (12/19) 63% of subjects went to their initial follow-up appointment in clinic. Nine were still active in clinic at 30 days and 4 were active at 6 months., Conclusions: This retrospective chart review shows promising preliminary data for managing OUD in an ED CDU. Such strategies have the potential to increase access to care in a vulnerable patient population., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Superior capsule reconstruction addresses massive rotator cuff tears using allografts and aims to restore the natural superior constraint of the shoulder and therefore shoulder biomechanics and function. There is no evidence relating to the histological incorporation of these grafts., Methods: 27 superior capsule reconstructions were performed between June 2016 and November 2017. Follow-up was with clinical assessment and Magnetic Resonance Imaging, to identify graft failure. Reverse total shoulder replacement was offered for ruptured grafts and the graft was sent for histological analysis along with the footprint of graft attachment where possible., Results: Five patients (18.5%) had evidence of graft failure, three of whom (11.1%) underwent revision procedures. Of the five ruptures, four failed at the glenoid insertion, and one was an intra-substance tear. Histological analysis showed extensive fibroblastic infiltration. The intra-substance tear showed some vascularity at the medial and lateral ends, and one of the glenoid pull-outs demonstrated micro-calcification and osteoid formation. There was no evidence of in-growth into the bone., Discussion: An inflammatory response to the grafts was seen, with neo-vascularisation, and micro-calcification observed. These findings are from ruptured grafts, so may not represent the characteristics of those which have not ruptured. Further evidence from explanted intact grafts could be gained to improve our understanding of its incorporation., Level of Evidence: Level IV evidence.

Background: Asthma-chronic obstructive pulmonary disease (COPD) overlap (ACO) represents the confluence of bronchial airway hyperreactivity and chronic airflow limitation and has been described as leading to worse lung function and quality of life than found with either singular disease process., Objective: We aimed to describe the prevalence and risk factors for ACO among adults across 6 low- and middle-income countries (LMICs)., Methods: We compiled cross-sectional data for 11,923 participants aged 35 to 92 years from 4 population-based studies in 12 settings. We defined COPD as postbronchodilator FEV 1 /forced vital capacity ratio below the lower limit of normal, asthma as wheeze or medication use in 12 months or self-reported physician diagnosis, and ACO as having both., Results: The prevalence of ACO was 3.8% (0% in rural Puno, Peru, to 7.8% in Matlab, Bangladesh). The odds of having ACO were higher with household exposure to biomass fuel smoke (odds ratio [OR], 1.48; 95% CI, 0.98-2.23), smoking tobacco (OR, 1.28 per 10 pack-years; 95% CI, 1.22-1.34), and having primary or less education (OR, 1.35; 95% CI, 1.07-1.70) as compared to nonobstructed nonasthma individuals. ACO was associated with severe obstruction (FEV 1 %, <50; 31.6% of ACO vs 10.9% of COPD alone) and severe spirometric deficits compared with participants with asthma (-1.61 z scores FEV 1 ; 95% CI, -1.48 to -1.75) or COPD alone (-0.94 z scores; 95% CI, -0.78 to -1.10)., Conclusions: ACO may be as prevalent and more severe in LMICs than has been reported in high-income settings. Exposure to biomass fuel smoke may be an overlooked risk factor, and we favor diagnostic criteria for ACO that include environmental exposures common to LMICs., (Copyright © 2018 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Context: Trazodone is an atypical antidepressant with no established safety in children. Previous case reports showed no complications at doses 50-500 mg in children. Our study objective is to characterize the clinical effects, dose-related toxicity, and establish triage dose for acute trazodone ingestions in children ≤6 years of age., Methods: Cases with acute trazodone ingestions in children ≤6 years of age between 2000 and 2015 were retrospectively reviewed. Data were analyzed for dose (mg/kg), clinical effects, management site, treatment, and outcome. Cases with coingestions, unknown outcome, or unknown dose were excluded., Results: A total of 84 patients (mean age 26.7 months, 35 females, 49 males) were included. Of those, 52 (61.9%) had no clinical effects; 29 (34.5%) had minor effects (vomiting, dizziness, headache); and three (3.6%) had moderate effects (ataxia, slurred speech, priapism). No major effects or deaths were observed. Moderate effects were manifested at doses ≥6.9 mg/kg. Priapism occurred in a 2-year-old child at a dose of 6.9 mg/kg. Sixteen (19%) patients were managed at home and 68 (81%) patients were referred to a HCF. Among those referred to a HCF, three (4.4%) patients had moderate effects with ingested dose ≥6.9 mg/kg. However, 27 (39.7%) patients of those referred to a HCF had an ingested dose <6 mg/kg and none of them manifested symptoms beyond minor effects. All referred patients had uneventful recovery and no sequela., Conclusions: Children should be referred for further evaluation in acute unintentional trazodone ingestions with doses ≥6 mg/kg.

Context: Across the world, tobacco is used in a variety of forms, including being smoked or added to a "quid" that is then chewed. We report a case of lead poisoning in a child from tobacco imported from Thailand., Case Details: A 12-year-old Thai immigrant boy had a blood lead level (BLL) of 6 mcg/dL on routine testing upon arrival to the United States, but which increased to 72 mcg/dL six months after his arrival. He was asymptomatic with unremarkable workup. At this time his father, mother and two siblings were also found to have elevated BLLs of 53, 16, 22, and 11 mcg/dL, respectively. Water, paint, food and cookware sources tested negative for lead, whereas samples of the father's dried tobacco leaves imported from Thailand contained 36.12 ppm (mcg/g) of lead. The mother admitted that both she and the patient used the tobacco as well. The child was chelated with oral succimer and his BLL decreased., Discussion: In our case, the source of the lead exposure was from the tobacco that the patient was chewing. Tobacco is often overlooked as a source of lead exposure, though it has been reported in the literature, both from direct smoking and from chewing, as well as through secondhand smoke. Toxicologists and health care professionals should consider cultural practices when evaluating patients with elevated BLLs.

Introduction: Steroidal alkaloids are found in plants of the genus Veratrum. Their toxicity manifests as gastrointestinal symptoms followed by a Bezold-Jarisch reflex: hypopnea, hypotension, and bradycardia. Some Veratrum steroidal alkaloids are also teratogens interfering with the hedgehog-2 signaling pathway, which causes cyclopsia and holoprosencephaly. We present a case of accidental poisoning from Veratrum parviflorum mistaken for the edible Allium tricoccum (ramps, wild leek)., Case History: A 27-year-old man and his 25-year-old wife presented to the emergency department with nausea, vomiting, hypotension, and bradycardia after foraging and ingesting plants that they believed to be a local native species of wild leek., Methods: We collected and analyzed the implicated fresh plant material and both patients' serum/plasma. We used liquid chromatography-mass spectroscopy and high-resolution electrospray ionization time of flight tandem mass spectrometry to extract and characterize steroidal alkaloids from the foraged plant and patients' serum., Results: Our V. parviflorum samples contained verazine, veratramine, veratridine, and cyclopamine., Discussion: Steroidal alkaloids have been previously isolated from Veratrum viride and Veratrum album and toxicity has been reported mainly from V. album species., Conclusion: V. parviflorum toxicity manifests with gastrointestinal and cardiac symptoms. Treatment is symptomatic and supportive as with previous case reports of toxicity with other Veratrum species.

Background: Allergic diseases are increasing in sub-Saharan Africa, but few studies have characterized the burden among adults., Objective: We conducted a study to evaluate the prevalence and risk factors of allergic disorders in urban and rural Uganda., Methods: We present a cross-sectional analysis of enrollment data from a population-based cohort study of adults aged ≥35 years in urban and rural Uganda. Sociodemographic and both lifetime and 12-month respiratory symptoms data were collected and spirometry was conducted following standard guidelines., Results: In 1,308 adults (median age 43.8 years and 52.3% female), we found an age-adjusted prevalence of 6.8% for asthma (9.8% urban, 4.3% rural; P < .001), 11.9% for allergic rhinitis (16.4% urban, 7.8% rural; P < .001), and 8.2% for eczema (9.9% urban, 7.8% rural; P = .15). Urbanization was the primary driver of asthma, accounting for 61.4% of cases (95% confidence interval [CI] 22.0% to 83.4%), and was the strongest risk factor for any allergic illness (odds ratio [OR] = 1.87, 95% CI 1.39-2.51). Parental asthma was not associated with allergic illness. Asthma was associated with a lower forced expiratory volume in 1 second (FEV 1 ) by 0.56 z scores (95% CI 0.33-0.80). We found a dose-response association between lower quintiles of the FEV 1 /forced vital capacity ratio and both hospitalization (OR = 1.77, 95% CI 1.21-2.59) and impairment in daily activities (1.65, 1.20-2.27)., Conclusions: Asthma and allergic rhinitis were twice as prevalent in urban settings. Asthma was associated with greater impairment and worse lung function outcomes. We identified a high prevalence of allergic disorders in Uganda, which can be expected to increase due to urbanization and resultant exposures throughout early development., (Copyright © 2017 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Introduction: Chronic obstructive pulmonary disease (COPD) will soon be the third leading global cause of death and is increasing rapidly in low/middle-income countries. There is a need for local validation of the Saint George's Respiratory Questionnaire (SGRQ), which can be used to identify those experiencing lifestyle impairment due to their breathing., Methods: The SGRQ was professionally translated into Luganda and reviewed by our field staff and a local pulmonologist. Participants included a COPD-confirmed clinic sample and COPD-positive and negative members of the community who were enrolled in the Lung Function in Nakaseke and Kampala (LiNK) Study. SGRQs were assembled from all participants, while demographic and spirometry data were additionally collected from LiNK participants., Results: In total, 103 questionnaires were included in analysis: 49 with COPD from clinic, 34 community COPD-negative and 20 community COPD-positive. SGRQ score varied by group: 53.5 for clinic, 34.4 for community COPD-positive and 4.1 for community COPD-negative (p<0.001). The cross-validated c statistic for SGRQ total score predicting COPD was 0.87 (95% CI 0.75 to 1.00). SGRQ total score was associated with COPD severity (forced expiratory volume in 1 s per cent of predicted), with an r coefficient of -0.60 (-0.75, -0.39). SGRQ score was associated with dyspnoea (OR 1.05/point; 1.01, 1.09) and cough (1.07; 1.03, 1.11)., Conclusion: Our Luganda language SGRQ accurately distinguishes between COPD-positive and negative community members in rural Uganda. Scores were correlated with COPD severity and were associated with odds of dyspnoea and cough. We find that it can be successfully used as a respiratory questionnaire for obstructed adults in Uganda., Competing Interests: Competing interests: RAW reports grants and/or personal fees from AstraZeneca/Medimmune, Boehringer Ingelheim, Contrafect, GlaxoSmithKline, Pfizer, Pulmonx, Roche, Spiration, Sunovion, Teva, Pearl Therapeutics, Merck and Bonti outside the submitted work.

Purpose: This study aims to address the clinical performance of a large diameter rigid gas permeable lens (LRGP) in a group of subjects with low-to-moderate (0.75-2.75 D) refractive astigmatism. An additional goal was to determine whether soft toric or LRGP contact lenses performed better objectively in the correction of astigmatism and to determine which modality is preferred by subjects., Methods: This was a multisite prospective cross-over clinical study. Ten asymptomatic contact lens wearers per site (four university clinics) were recruited and randomly assigned to group A or group B. Group A was assigned to start wearing Comfilcon A soft toric lens first, for two weeks, and then crossed over to LRGP lenses (Boston XO, 14.3 mm diameter miniscleral lens). Group B initially wore LRGP lenses and then crossed over to soft toric lenses. For each type of lens worn, low-contrast and high-contrast visual acuity (VA) were evaluated at distance. At the conclusion of the study, after two months, all subjects completed a questionnaire in which they were asked to indicate their preference for one type of lens (soft toric or LRGP) and to rate the quality of vision in day-to-day activities., Results: Thirty-six of 38 (94.7%) subjects completed the study with 75% preferring the vision of the LRGP lens as compared to the soft toric lenses worn in the study. 52.7% expressed a preference to continue with this modality despite only 38.8% reporting that these LRGP lenses are easy or very easy to handle. Wear time, subjective comfort, and subjective vision ratings exhibited no significant difference between the two groups., Conclusions: In a population of asymptomatic contact lens wearers, LRGP lenses can be considered as a good alternative to soft toric lenses for the correction of refractive astigmatism.

Background: A recent study found lower self-reported prevalence of tobacco smoking in a peri-urban area of Lima, Peru than previously reported in urban samples. These regions encompass substantial proportions of Peru's population - ones at greater risk of disease due to reduced healthcare access - but have been less often studied. We validate low smoking prevalence with urine cotinine and characterize chronic disease and lung function outcomes between non-, occasional, and daily smokers., Methods: Data are from the CRONICAS Cohort Study, a population-based longitudinal study in four low-resource Peruvian settings, which began in 2010. Of a baseline cohort of 2978 adults, we prospectively followed 2583 (87%) to determine prevalence of chronic illness., Results: In a baseline sub-sample of 382 participants, median adjusted cotinine was 0.0 mcg/mg (IQR 0-0) for both self-reported non-smokers and occasional smokers compared to 172.3 mcg/mg (IQR 0-709.2) for daily smokers. Creatinine-adjusted cotinine validated daily smoking prevalence of 4.7% at a cutoff of 100 mcg/mg. Kappa statistic for daily smoking and creatinine- adjusted cotinine ≥100 mcg/mg was 0.65 (95% CI 0.47, 0.83), indicating substantial agreement. At baseline, we found 3.3% daily and 8.9% occasional smoking by self-report for the full cohort. Follow-up indicated little difference in chronic disease prevalence between groups. Daily smokers trended toward having a greater decline in FVC (-1%; 95% CI -2.9, 0.8) and FEV 1 (-1.3%; 95% CI -3.2, 0.6) over 40 months when compared to non-smokers, whereas the decline in lung function for occasional smokers was similar compared to non-smokers (-0.2% FVC; 95% CI -1.5, 1.0) and (0% FEV 1 ; 95% CI -1.3, 1.3)., Conclusions: Our data places Peru within a previously-described pattern of smoking found in much of Latin America, favoring occasional over daily smoking and low cigarette consumption. We determine that there are not significant differences between smoking groups concerning chronic disease outcomes. We favor distinguishing between daily and occasional smokers in order to accurately characterize these low-use populations.

According to the NIH, about 275000 patients receive treatment with 5-Fluorouracil (5-FU) and more than 1300 die from 5-FU toxicity every year from life-threatening myelosuppression, gastrointestinal complications, and neurotoxicity. Immunocompromised persons are at higher risk of developing toxicity. Recently uridine triacetate (Vistagard®) has been approved by the Food and Drug Administration (FDA) as the only specific antidote available for 5-FU poisoning. In a clinical trial (n=135), 96% of patients with 5-FU toxicity recovered after treatment, where as in a historical control group only 10% survived. This is the first published case report of survival after 5-FU overdose who also was immunocompromised from HIV/AIDs. A 52year old male with history of HIV/AIDS (CD4 70), CNS toxoplasmosis and anal cancer presented to the emergency department after realizing he had received an entire course of 5-FU in 24 instead of 96h. Treatment with uridine triacetate was arranged in the emergency department. After receiving treatment the patient was asymptomatic and had an uncomplicated hospital course. 5-FU poisoning must be recognized early as uridine triacetate is approved by the FDA for use within 96h following the end of 5-FU administration. Emergency medicine physicians should promptly recognize and treat 5-FU poisoning. However, this may be challenging as patients may not seek medical attention until many hours or several days after last administration since symptoms are often delayed with 5-FU poisoning., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Silicone finger arthroplasties are used widely, especially for metacarpophalangeal joint replacement in patients with inflammatory arthritis. Implant failure is well recognized. The rates of failure in vivo differ substantially from experience in vivo. One cause of failure is felt to be post-operative ulnar deviation. The aim of our study was to test the effect of ulnar deviation testing on silicone finger implants. We tested 12 implants in three groups of four implants. The implants were submerged in a bath of Ringer's solution at 370 °C throughout the experiment and tested in a rig held in 0°, 10° and 20° deviation. The rig was cycled at 1.5 Hz from 0°-90°. The implants were inspected every 500,000 cycles until a total of 4 million cycles. There was consistently increased wear and supination plastic deformity in going from 0°-20° deviation. This study confirms the adverse effects of ulnar deviation on silicone finger implant wear. It is likely that this combines with lateral pinch forces and sharp bone edges to cause catastrophic silicone implant failure., Level of Evidence: III.

Introduction: Little is known about the factors driving decision-making among emergency department (ED) providers when prescribing opioid analgesics (OA). The aim of this pilot study was to identify the importance of factors influencing OA-prescribing decisions and to determine how this varied among different types of providers., Methods: This was an observational cross-sectional survey study of 203 ED providers. The importance of decisional factors was rated on a 5-point Likert scale. Differences between provider groups were tested using Chi-squared or ANOVA tests where applicable., Results: Overall, 142/203 (69.9 %) potential respondents participated in the study. The five highest-rated factors were (mean ± SD) patient's opioid prescription history (4.4 ± 0.8), patient's history of substance abuse or dependence (4.4 ± 0.7), diagnosis thought to be the cause of patient's pain (4.2 ± 0.8), clinical gestalt (4.2 ± 0.7), and provider's concern about unsafe use of the medication (4.0 ± 0.9). The importance of 6 of 21 decisional factors varied significantly between different groups of providers., Conclusion: In this pilot study of ED providers, the self-reported importance of several factors influencing OA-prescribing decisions were significantly different among attending physicians, resident physicians, and advanced practice providers. Further investigation into how ED providers make OA-prescribing decisions is needed to help guide interventions aimed at improving appropriate pain management., Competing Interests: The authors have no conflicts of interest to report. Funding Sources This study is supported in part by the ECIC Faculty Pilot Grant Program from the Emory Center for Injury Control, Emory University; CDC Grant #5R49CE001494

Background: Carpet vipers (Echis) are found across the semiarid regions of west, north, and east Africa; west, south, and east Arabia; parts of Iran and Afghanistan north to Uzbekistan; and in Pakistan, India, and Sri Lanka. Recently, a new species belonging to the Echis genus, Echis omanensis has been recognized in Oman. Not much is known about the clinical manifestations of envenomation from its bite., Case Report: A 63-year-old snake keeper presented to the emergency department shortly after being bitten by an Oman carpet viper (E. omanensis). The incident occurred during expression of the venom at a research center. The patient complained of severe pain and swelling of the left index finger, which extended to the mid-forearm within 1 h. His vital signs remained stable, with no evidence of systemic manifestations. He was treated initially with analgesics and tetanus toxoid. Due to rapidly progressive swelling and the potential for a delayed coagulopathy, the Saudi National Guard polyvalent snake antivenom was administered according to the Ministry of Health protocol. The patient was admitted to the intensive care unit, remained hemodynamically stable, and had normal serial coagulation tests, with subsequent resolution of the swelling., Conclusion: We report the first case of an E. omanensis bite in which the patient developed rapidly progressive local toxicity, which improved after administration of the Saudi polyvalent antivenom.

Background: Lateral end of clavicle fractures can be a challenge, with a 20% to 30% non-union rate if treated non-operatively. Several operative options exist, each having their own merits and some having potential disadvantages. The Minimally Invasive Acromioclavicular Joint Reconstruction (MINAR®) (Storz, Tutlingen, Germany) set uses an Orthocord (Depuy Synthes Mitek, Leeds, UK) suture and two Flip Tacks (Storz) via a transclavicular-coracoid approach to reconstruct the coracoclavicular ligaments., Methods: Referrals were made to two senior surgeons at separate institutions regarding Robinson Type 3 fractures of the lateral end of the clavicle. All patients were treated with MINAR implant via a minimally invasive approach. Two-year follow-up was obtained using the Oxford Shoulder Score (OSS) and the Quick DASH (Disability of the Arm Shoulder and Hand) score., Results: Sixteen cases of acute fractures of the lateral end of the clavicle were included in this series. At final follow-up, the mean OSS was 44.75 (range 35 to 48) and the median Quick DASH score was 2.3 (range 0 to 35.9). Fifteen patients achieved bony union (one asymptomatic non-union) and there were no complications or re-operations., Conclusions: The MINAR is reproducible and safe when treating lateral end of clavicle fractures. We consider that, over the short- to mid-term, it achieves results equivalent to those for other implants.

Context: Prescription opioid abuse is a major public health concern and an ongoing epidemic in the United States. Loperamide is a widely available and inexpensive over-the-counter antidiarrheal with peripheral mu-opioid receptor activity. Online resources discuss the use of loperamide for the amelioration of withdrawal symptoms or recreational abuse. We describe the clinical course of 5 patients abusing loperamide, 3 of whom had life-threatening cardiac arrhythmias., Methods: In this observational case series, patients with cardiac arrhythmias or history of loperamide abuse with cardiac arrhythmias were identified; 5 patients were identified and 4 of the 5 patients were seen directly at the bedside. Clinical profile and outcome of patients is reported., Results: We report 5 patients with history of loperamide abuse; 3 of the 5 patients had life-threatening cardiac arrhythmias. One of the patients experienced a second life-threatening arrhythmia after he resumed loperamide abuse. Loperamide levels were obtained in 4 of the 5 patients and were at least one order of magnitude greater than therapeutic concentrations. Discontinuation of loperamide resulted in complete resolution of cardiac conduction disturbances., Conclusion: This case series describes several patients with cardiac conduction abnormalities and life-threatening ventricular arrhythmias temporally related to loperamide abuse. With the recent efforts to restrict the diversion of prescription opioids, increasing abuse of loperamide as an opioid substitute may be seen. Toxicologists should be aware of these risks and we urge all clinicians to report such cases to FDA Medwatch(®).

Introduction: Clonidine is an imidazoline derivative antihypertensive medication that is also used as adjunctive therapy for neuropathic pain disorders via topical administration. Clonidine overdose can manifest both central and peripheral alpha-adrenergic agonist effects., Case Report: A 23-year-old man presented to an emergency department with altered mental status, bradycardia, and hypertension after suspected overdose. He had rubbed a specially compounded medicinal cream over his entire body containing clonidine 0.2 % (w/w), gabapentin 6 %, imipramine 3 %, ketamine 10 %, lidocaine 2 %, and mefenamic acid 1 %. The patient presented with severe hypertension, bradycardia, and altered mental status. He was found to have a subarachnoid hemorrhage and was treated for hypertensive emergency. Toxicological analysis of initial blood samples revealed a serum clonidine concentration of 5,200 ng/ml. At 6-month follow-up, the patient had made a full recovery., Discussion: There are limited reports of topical clonidine toxicity, and to our knowledge, this case involves the highest concentration yet reported following clonidine overdose by any route of exposure. The severely elevated serum clonidine concentration found in our patient demonstrates the possibility of toxicity resulting from inappropriate use of such a product. At high serum concentrations, the pharmacodynamic effects of clonidine appear to cause significant peripheral alpha-1 adrenergic stimulation. Toxicologists should be aware of the increasing use of topical clonidine preparations for the treatment of neuropathic pain and the potential for toxicity.

Safety concerns regarding cobalt-containing metal alloy hip prosthetics (Co-HP) have resulted in product recalls, a medical device alert, and issuance of guidance for clinicians. Recently, cases of suspected prosthetic hip-associated cobalt toxicity (PHACT) from Co-HP have been reported. Although little is known about suspected PHACT, these patients may be referred to medical toxicologists for evaluation and management recommendations. We searched MEDLINE, EMBASE, and unpublished abstracts from toxicology scientific meetings for references relevant to PHACT. Authors independently screened publications for inclusion criteria: publication in English, human study population, subject(s) are symptomatic (except for isolated hip pain), and cobalt values in any matrix (blood, serum, urine, CSF, synovial fluid) available for review. Data from 10 cases are reviewed. Patients with suspected PHACT had findings consistent with cobalt toxicity, including thyroid, cardiac, and neurologic dysfunction. Signs and symptoms appeared between 3 and 72 months after arthroplasty (median 19 months). Neurologic symptoms were most common. Ancillary testing varied considerably. All patients had elevated cobalt levels in one or more matrices. Enhanced elimination was attempted in 27 % of patients. At this time, the information currently available regarding patients with suspected PHACT is inadequate to guide clinical decision making. No consensus has been reached regarding the management of Co-HP patients with systemic symptoms. Indications for chelation have not been established and require further study. Improved case definitions, improved surveillance, and controlled studies are needed to elucidate the scope of this problem and guide future investigations.

Background: Medical toxicologists are frequently consulted when young patients present with delirium attributed to suspected poisoning. Medical toxicologists should be aware of non-toxicological mimics of delirium. We describe two patients ultimately diagnosed with anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis for which a toxicological consultation was requested to evaluate for neuroleptic malignant syndrome (NMS)., Case 1: A 21 year old male was sent from a psychiatric facility for new, worsening psychotic symptoms. He had autonomic instability, confusion, and hyper-reflexia. He was treated for NMS without improvement, and after an extensive workup was unrevealing, he was discharged home with significant cognitive dysfunction. Stored CSF later tested positive for anti-NMDAR antibodies., Case 2: A 27 year old female was sent from a psychiatric facility for a seizure and new psychiatric symptoms. She was agitated and had violent, alternating extremity flexion and extension along with autonomic instability. She was treated for NMS, rhabdomyolysis, and rabies before analysis of CSF demonstrated anti-NMDAR antibodies. Treatment included surgical resection of a suspicious ovarian cyst, steroids and IVIG, with moderate improvement., Discussion: Autoimmune syndromes of the central nervous system result from receptor dysfunction after an antibody response to extracellular or intracellular antigens, such as subunits of the NMDA receptor. The NMDA subunits NR2b and NR2a, in addition to the N-terminal region of the glycine binding NR1 subunit, have been implicated. Typical features such as memory loss, movement disorders, and hallucinations reflect the density and distribution of neuronal NDMA receptors. As young people, particularly young women, are predominantly affected, initial symptoms may be attributed to encephalopathy from drug abuse or schizophrenia. Toxicologists may be consulted as many features mimic NMS. Serum and cerebrospinal fluid can be checked for anti-NMDAR antibodies as part of a paraneoplastic or meningioencephalitis panel. Effective treatments have been described and include surgical resection and immunosuppressive medications.

Introduction: We conducted a prospective randomized controlled study on the influence of multiple doses of activated charcoal (MDAC) in patients with supratherapeutic serum phenytoin levels;, Methods: Patients with serum phenytoin levels greater than 30 mg/L upon presentation to the ED were recruited from two urban teaching hospitals. Patients enrolled were older than 18, nonpregnant, able to tolerate activated charcoal by mouth and able to give written consent. They were randomized to receive 50 g activated charcoal by mouth every 4 hours or no activated charcoal. They continued in the study until the patient was discharged or the serum level was <25 mg/L. Serum levels were drawn every 6 hours initially, then every 24 hours after the 1st day. The presence of gait abnormalities and nystagmus was recorded and mini-mental status exam (MMSE) scores were collected from each patient enrolled. Time to reach subtoxic levels was recorded;, Results: Seventeen patients were enrolled in the study. Seven patients received MDAC, eight patients served as controls and two patients who were initially enrolled as controls inadvertently received one dose of activated charcoal and were excluded from the analysis. Both groups were comparable in age and all were male. The median time to reach a subtoxic level was 41.1 hours (range, 11.6-196) and 19.3 hours (range, 13-33) in the control and charcoal groups, respectively (p = 0.049). The median and range peak serum levels were 40.0 hours (range, 32.0-47.6) and 35.6 hours (range, 32.5-40.0) in the control and charcoal groups, respectively (p = 0.082). The median and range MMSE scores were 20 points (range, 12-30) and 19.5 points (range, 16-29) in the control and charcoal groups, respectively;, Conclusion: Further study is needed to determine if MDAC decreases the time to reach a subtoxic level of phenytoin in patients with supratherapeutic phenytoin levels.

Introduction: Self-exposure is a leading method for suicide both in the United States and worldwide and thus is a major preventable public health issue. Surrogate decision makers are tasked with making medical decisions for the patient while keeping the patient's wishes in mind. Decisions related to code status become more complicated when the patient's situation is the result of a suicidal act. The objectives were to 1) determine how frequently Do Not Resuscitate orders (DNR orders) are placed for the intentionally self-exposed (ISE) patient using the Regional Poison Control Center (RPCC) data, and 2) identify if DNR orders in intentionally self-exposed patients were placed before or after development of poor prognostic signs., Methods: We analyzed all exposure-related deaths reported to the RPCC from January 1, 2000 to December 31, 2010. We reviewed data for the following: exposure intent, exposure substance, outcome, age, code status, date of DNR/withdrawal of care order, previous suicide attempts, and poor prognostic signs., Results: Of the 476 total deaths, nearly half were the result of an intentional self-exposure (n= 235; 49.4%). Most deaths, when code status was reported, had advanced cardiac life support, or "full codes" (n=131; 55.6%). Of the total deaths with a DNR or withdrawal of care order (n=104), over half were from an ISE (n=55; 52.9%). A higher percentage of the ISEs had a DNR order/withdrawal of care order; however, it was not a statistically significant difference OR 1.23 (95% CI 0.64, 2.37). of intent, patients treated as full codes were on average 19.5 years younger than the DNR orders group. Only 2 DNR orders were placed prior to development of poor prognostic signs. Unintentional self-exposures consumed a mean of 1.4 substances (range 1 to 4). ISEs consumed a mean of 2.3 substances (range 1 to 19)., Conclusion: People are often asked to make life-and-death decisions for a loved one. The nature of the exposure can complicate the issue if the exposure has an antidote or is known to have a limited effect. Further study is needed to assess the extent of these cases and to identify optimal management guidelines or policy to aid both the medical teams caring for these patients and the surrogate decision makers.

Background: There were 900 exotic venomous snakebites reported from 2000 to 2009. The Association of Zoos and Aquariums' recommends institutions housing venomous reptiles have protocols for appropriate and timely transport of envenomed individuals to hospitals. The study objective was to evaluate functional aspects and potential problems of our emergency operation procedure designed for handling the response to an exotic venomous snakebite during implementation via a simulated drill. The emergency operation procedure consists of two protocols, the protocol for zoo personnel and exotic snakebite protocol for hospital personnel., Methods: Before the exercise the poison center (PC), zoo, Emergency Medical Services (EMS), receiving hospital emergency department (ED), and pharmacy were contacted. The emergency operation procedure was reviewed to determine areas of deficiency. A checklist of all required actions for each participating institution was created for use during the exercise. The exercise was divided into four phases: zoo, EMS, PC, and ED. Each phase was evaluated by an independent observer., Results: Review of the emergency operation procedure revealed sufficient and easy to follow information for zoo personnel. However, the exotic snakebite protocol for hospital personnel lacked details regarding signs and symptoms expected from each exotic venomous species in the zoo; and indications, dosing, and instructions on reconstitution for each of the antivenom carried by the zoo. Zoo, EMS, ED, and PC personnel completed 95%, 90%, 83%, and 25% of the required tasks, respectively. The PC encountered problems communicating the exotic snakebite protocol for hospital personnel to the ED due to phone and fax equipment failures. Creative solutions to the PC system issues were not identified in a timely manner. Despite the shortcomings, the time from simulated envenomation to antivenom (AV) administration was under an hour., Conclusions: This drill identified several issues leading to revision of our exotic snakebite protocol for hospital personnel. We also identified suboptimal PC response in the application of the emergency operation procedure. We encourage every poison center in cooperation with local zoos to perform a similar exercise.

Poison center consultations for potential toxic alcohol poisonings are challenging because blood levels are typically not immediately available. The primary objective of this study was to determine whether readily obtainable laboratory values can be used to accurately and rapidly diagnose these poisonings. Over a 15-month period, patients with a history of toxic alcohol ingestion or a metabolic acidemia (pH ≤ 7.30 or serum bicarbonate ≤ 18 mEq/L) that prompted a poison center consultation were enrolled. A predictive logistic regression model was used to assess the combined ability of serum pH, calcium, osmolar gap, and anion gap levels to predict a final diagnosis of toxic alcohol poisoning. There were 102 subjects included in the analysis. A total of 44% (45/102) patients had a final diagnosis of ethylene glycol (EG) poisoning. Higher levels of calcium, osmolar gap, and anion gap were independently associated with statistically significant or marginally significant increases in the odds of a final diagnosis of EG poisoning. The c-index was estimated at 0.81, indicating that the model showed a reasonable ability to discriminate EG cases from others. The final model had a sensitivity and specificity of 78% and 89%, respectively, and positive and negative predictive values of 84% and 83% respectively. The combination of elevated calcium, osmolar gap, and anion gap is associated with a high likelihood of EG poisoning, but clinician gestalt is still essential for its diagnosis. Further refinement of the model is needed.

Introduction: Selenium is an essential trace element, but can be toxic in excess. In May 2008, US FDA reported 201 individuals with adverse reactions to liquid nutritional supplements containing excess selenium and chromium resulting in the largest epidemic of selenosis in the history of the United States., Objective: To describe the clinical features, biomonitoring data of selenium levels, and the estimated total dose of selenium ingestions of nine patients with selenium toxicity who presented after use of a liquid dietary supplement with a formulation error., Methods: A retrospective observational case series was performed on nine patients presenting to our medical toxicology clinic between March 2008 and May 2008 with symptoms of selenosis after consuming a nutritional supplement. Institutional IRB approval was obtained for this case series., Results: Supplement testing revealed almost 200 times the reported amount of selenium. There were 5 males and 4 females and their ages ranged from 15 to 57 years (median 46 years, mean 44.2 years). The mean estimated cumulative dose of selenium ingested in our patients was 1.3 gram over a mean period of 37.5 days (10-60 days). In each case, the symptoms of selenium toxicity manifested within 1 week from the start of ingestion. Initial symptoms included alopecia, dystrophic fingernail changes, GI symptoms, and memory difficulties. The initial whole blood selenium concentrations ranged from 150 to 732 mcg/L (reference mean range 123-193 mcg/L) at an average of 27 days post cessation of the formula. The urinary selenium concentrations ranged from 41 to 220 mcg/g Creat (reference < 25 mcg/g Creatinine). None of the patients required more than supportive care for symptoms and none required hospitalization., Conclusion: Selenium is an essential element, which can result in significant toxicity if ingested in large amounts.