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1. Disparate Utilization of Urine Drug Screen Nationwide in the Evaluation of Acute Chest Pain

Author

Overbeek, Daniel L., Janke, Alexander T., Watson, C. James, Salhi, Rama A., Kim, Erin, Boatright, Dowin, and Losman, Eve D.

Subjects
Toxicology, Urine Drug Screening, Chest Pain, Racial Disparities
Abstract

Introduction: Urine drug screens (UDS) have unproven clinical utility in emergency department (ED) chest pain presentations. A test with such limited clinical utility may exponentiate biases in care, but little is known about the epidemiology of UDS use for this indication. We hypothesized that UDS utilization varies nationally across race and gender.Methods: This was a retrospective observational analysis of adult ED visits for chest pain in the 2011–2019 National Hospital Ambulatory Medical Care Survey. We calculated the utilization of UDS across race/ethnicity and gender and then characterized predictors of use via adjusted logistic regression models.Results: We analyzed 13,567 adult chest pain visits, representative of 85.8 million visits nationally. Use of UDS occurred for 4.6% of visits (95% CI 3.9%-5.4%). White females underwent UDS at 3.3% of visits (95% CI 2.5%-4.2%), and Black females at 4.1% (95% CI 2.9%-5.2%). White males were tested at 5.8% of visits (95% CI 4.4%-7.2%), while Black males were tested at 9.3% of visits (95% CI 6.4%-12.2%). A multivariate logistic regression model including race, gender, and time period shows significantly increased odds of ordering UDS for Black patients (odds ratio [OR] 1.45 (95% CI 1.11-1.90, p = 0.007)) and male patients (OR 2.0 (95% CI 1.55-2.58, p < 0.001) as compared to White patients and female patients.Conclusion: We identified wide disparities in the utilization of UDS for the evaluation of chest pain. If UDS were used at the rate observed for White women, Black men would undergo nearly 50,000 fewer tests annually. Future research should weigh the potential of the UDS to magnify biases in care against the unproven clinical utility of the test.

Published
2023

4. Contributors

Author

Adams, Axel, primary, Affun-Adegbulu, Clara, additional, Al-Rasheed, Rakan S., additional, Alaska, Yasser A., additional, Aldawas, Abdulaziz D., additional, Alesa, Saleh Ali, additional, Alexander, George A., additional, Alhadhira, Abdullah Ahmed, additional, Alhajjaj, Fahad Saleha, additional, Alhazmi, Hazem H., additional, Alhussaini, Zainab Abdullah, additional, Aljerian, Nawfal, additional, Aljohani, Majed, additional, AlKhaldi, Khaldoon H., additional, Alkhattabi, Eyad, additional, Allen, Bryant, additional, Almand, Austin, additional, Alnoaimi, Moza M., additional, Alotaibi, Mohammad, additional, Alpert, Evan Avraham, additional, Alrusayni, Yasir A., additional, Alshammari, Mai, additional, Alsulimani, Loui K., additional, Amanullah, Siraj, additional, Anderson, Arian, additional, Arastehmanesh, David, additional, Ardalan, Ali, additional, Argote-Araméndiz, Killiam A., additional, Artenstein, Andrew W., additional, Bailey, Olivia E., additional, Baker, Russell, additional, Balsari, Satchit, additional, Banner, Gregory T., additional, M, Fermin Barrueto, additional, Bartels, Susan A., additional, Baugh, Joshua J., additional, Berg, Frederic, additional, Bhola, Vijai, additional, Binder, William, additional, Bortolin, Michelangelo, additional, Bounes, Vincent, additional, Bouton, Michael, additional, Brown, Natasha, additional, Jr, Frederick M. Burkle,, additional, Burnett, Lynn Barkley, additional, Burns, Michele M., additional, Sr, Nicholas V. Cagliuso,, additional, Cahill, John, additional, Callaway, David W., additional, Caneva, Duane C., additional, Cattamanchi, Srihari, additional, Caycedo, Alejandra, additional, Cetaruk, Edward W., additional, Chacko, Sneha, additional, Chang, James C., additional, Chiang, Crystal, additional, Chiu, David T., additional, Ciottone, Gregory R., additional, Ciottone, Jonathan Peter, additional, Ciottone, Melissa A., additional, Ciottone, Robert A., additional, Ciottone, Robert G., additional, Ciottone, Vigen G., additional, Clark, Alexander, additional, Clark, Jonathan, additional, Conley, Sean P., additional, Cono, Joanne, additional, Cooper, Arthur, additional, Cormier, Scott B., additional, Court, Michael F., additional, Cunningham, Cord W., additional, Czarnecki, Fabrice, additional, Davis, Supriya, additional, Davis, Timothy E., additional, DeMers, Gerard, additional, Dilling, Sharon, additional, Djalali, Ahmadreza, additional, Donahoe, Timothy, additional, Donahue, Joseph, additional, Dresser, Caleb, additional, Dylik, Jason, additional, Easter, Benjamin, additional, Eastman, Alexander, additional, Ebbeling, Laura, additional, Emetarom, Chigozie, additional, Eyal, Nir, additional, Eyre, Andrew J., additional, Freeman, David J., additional, Friedman, Franklin D., additional, Fritz, Christie, additional, Fung, Frederick, additional, Gallahue, Fiona E., additional, Garbern, Stephanie Chow, additional, Gebhart, Mark E., additional, Gluckman, William A., additional, Goolsby, Craig, additional, Gougelet, Robert M., additional, Granholm, Fredrik, additional, Greenough, P. Gregg, additional, Grimes, Jennifer O., additional, Grosse, Steve, additional, Grossman, Shamai A., additional, Jr, John T. Groves, additional, Guidotti, Tee L., additional, Guo, George, additional, Haessler, Sarah, additional, Hall, Matthew M., additional, Hardin, John W., additional, Harrell, Mason, additional, Hart, MD, Alexander, additional, Harvey, Melissa, additional, Hertelendy, PhD, Attila J., additional, Hiremath, Nishanth S., additional, Hitchens, Jordan, additional, Holstege, Christopher P., additional, Horne, Simon T., additional, Horng, Steven, additional, Hosin, Amer, additional, House, Hans R., additional, Ingrassia, Pier Luigi, additional, Issa, Fadi S., additional, Jacoby, Irving “Jake”, additional, Jaiswal, Rajnish, additional, Jay, Gregory, additional, Jenkins, J. Lee, additional, Joseph, Josh W., additional, Kappler, Shane, additional, Keim, Mark E., additional, Kelman, Julie, additional, Ketterer, Andrew R., additional, Khan, Anas A., additional, Kharel, Ramu, additional, Kharod, Chetan U., additional, Kirsch, Thomas D., additional, Knopov, Anita, additional, Kravitz, Max, additional, Lee, J. Austin, additional, Lemery, Jay, additional, Leventhal, Evan L., additional, Loughlin, Jesse, additional, Ludy, Stephanie, additional, Maguire, Brian J., additional, Mahon, Selwyn E., additional, Maniscalco, Paul M., additional, Manners, Philip, additional, Marcus, Leonard Jay, additional, Margus, Colton, additional, Masri, Taha M., additional, Matthews, Jeff, additional, McKay, Sean D., additional, McKinney, Zeke J., additional, McLellan, Robert K., additional, McNulty, Eric J., additional, Mehkri, Faroukh, additional, Mehta, Mandana, additional, Mendelsohn, Rebecca A., additional, Merin, Ofer, additional, Milsten, Andrew, additional, Molé, Dale M., additional, Molloy, Michael Sean, additional, Morelli, Ilaria, additional, Mothershead, Jerry L., additional, Mulhern, John, additional, Mullendore, Nicole F., additional, Musisca, Nicholas J., additional, Naganathan, Sonya, additional, Nathanson, Larry A., additional, Nelson, Erica L., additional, Nelson, Lewis S., additional, Newbury, Bradford A., additional, Newbury, Kimberly, additional, O’Neill, Ansley, additional, Obernier, Robert, additional, Olagnero, Jacopo M., additional, Oostrom-Shah, Leonie, additional, Ordun, Catherine Y., additional, Parazynski, Scott, additional, Park, Andrew J., additional, Partridge, Robert, additional, S, Jeffrey, additional, Phillips, James P., additional, Pinter, Emily, additional, IV, David P. Polatty, additional, Popieluszko, Patrick, additional, Porcaro, William, additional, Proano, Lawrence, additional, Pruitt, Peter B., additional, Qureshi, Moiz, additional, Ragazzoni, Luca, additional, Rashid, Murtaza, additional, Rega, Paul Patrick, additional, Reilly, Michael J., additional, Restuccia, Marc C., additional, Rifino, James J., additional, Robben, Paul M., additional, Rosenblatt, Joy L., additional, Ryan, Kevin M., additional, Rybasack-Smith, Heather, additional, Salway, Richard James, additional, Samo, Daniel, additional, Sanchez, Leon D., additional, Sanford, Shawn M., additional, Sarin, Ritu R., additional, Sarma, Deesha, additional, Schacht, Jesse, additional, Schwind, Valarie, additional, Shapiro, Geoffrey L., additional, Sheehan, Joshua, additional, Shreve, Brian, additional, Simonyan, Grigor, additional, Smith, Devin M., additional, MD, E. Reed Smith,, additional, MA, Jack E. Smith,, additional, Smith, Montray, additional, Smulowitz, Peter B., additional, Snyder, Angela M., additional, Solano, Joshua J., additional, Stenson, Bryan A., additional, Stewart, Charles, additional, Stewart, M. Kathleen, additional, Sullivan, Patrick, additional, Supple, Jared S., additional, Tin, Derrick, additional, Valente, Jonathan Harris, additional, Vear, Kathryn M., additional, Vidyalakshmi, P.R., additional, Vilas, Faith, additional, Vilke, Gary M., additional, Villano, Janna H., additional, Voskanyan, Amalia, additional, Watson, C. James, additional, Weber, Nancy, additional, Weiner, Scott G., additional, Weinstein, Brielle, additional, Weinstein, Eric S., additional, Werner, Jordan R., additional, MD, Roy Karl Werner,, additional, Whitledge, James D., additional, Wiener, Sage W., additional, Wiesner, Lauren, additional, Williams, Kenneth A., additional, Wing, Robyn, additional, Wolfe, Richard E., additional, Wong, Wendy Hin-Wing, additional, Woolard, Robert, additional, Wuthisuthimethawee, Prasit, additional, and Youssef, Nadine A., additional

Published
2024
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8. Novichok

Author

Watson, C. James, primary, Whitledge, James D., additional, and Chai, Peter R., additional

Published
2023
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10. Difficult Intraoperative Heparinization Following Andexanet Alfa Administration

Author

Watson, C. James, Zettervall, Sara L., Hall, Matthew M., and Ganetsky, Michael

Abstract

Direct oral anticoagulants are now commonplace, and reversal agents are recently becoming available. Andexanet alfa (AnXa), approved by the United States Food and Drug Administration in 2018, is a novel decoy molecule that reverses factor Xa inhibitors in patients with major hemorrhage. We present a case of a 70-year-old man taking rivaroxaban with hemodynamic instability from a ruptured abdominal aortic aneurysm. He received AnXa prior to endovascular surgery, and intraoperatively he could not be heparinized for graft placement. Consideration should be given to the risks and benefits of AnXa administration in patients who require anticoagulation after hemorrhage has been controlled.

Published
2019

20. Characterization of pediatric beta‐adrenergic antagonist ingestions reported to the National Poison Data System from 2000 to 2020.

Author

Watson, C. James, Monuteaux, Michael C., and Burns, Michele M.

Subjects
EVALUATION of medical care, FOOD consumption, RETROSPECTIVE studies, ADRENERGIC beta blockers, POISON control centers, RESEARCH funding, DESCRIPTIVE statistics, HYPOGLYCEMIA, HYPOTENSION, BRADYCARDIA, CHILDREN
Abstract

Background: When ingested by children, small quantities of beta‐adrenergic antagonists (BAA) are described as dangerous and even potentially lethal ("one pill can kill"). We characterize demographics, clinical characteristics, and the rate of serious outcomes among pediatric patients with reported BAA ingestions. Methods: This study was a retrospective review of U.S. patients <20 years old with reported single‐agent BAA ingestions presenting to a health care facility between January 2000 and February 2020 for whom a poison control center was consulted. Data were abstracted from the National Poison Data System (NPDS). Medical outcomes were assessed by the NPDS scale of no effect, minor effect, moderate effect, major effect, and death. All relevant NPDS fatality narratives were reviewed. Results: A total of 35,436 reported exposures were identified. A total of 29,155 (82.3%) were <6 years old, of which 29,089 (99.8%) were unintentional. Twenty‐five patients (<0.1%) <6 years old had major effects. A total of 2316 (8.8%) of patients with no/mild effects were admitted to a critical care unit. Of all cases, 1460 (4.1%) had hypotension and 1403 (4.0%) had bradycardia. One hundred nineteen (0.3%) developed hypoglycemia. The only four fatalities resulted from intentional ingestions in patients >10 years old who sustained cardiac arrest in the prehospital setting. Conclusions: Reported BAA ingestions in this multiyear national pediatric cohort caused infrequent toxicity, and no fatalities resulted from an unintentional ingestion. The frequency of bradycardia, hypotension, and hypoglycemia were low. While severely poisoned patients require aggressive treatment, 8.8% of patients were admitted to a critical care unit despite having no or mild effects, which suggests an opportunity to reduce resource utilization. [ABSTRACT FROM AUTHOR]

Published
2023
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24. Thiocyanate toxicity: a teaching case.

Author

Watson, C. James, Overbeek, Daniel L., Allegri-Machado, Gabriella, Kellogg, Mark D., Patterson, Al, McAlvin, J. Brian, and Burns, Michele M.

Subjects
*ION selective electrodes, *CARDIOTOXICITY, *CELL respiration, *CYANIDES, *MEDICAL sciences, *SALICYLATES
Abstract

Introduction: Thiocyanate can cause gastrointestinal, neurologic, and cardiovascular toxicity. Additionally, it interferes with multiple laboratory assays. We present a case of acute thiocyanate toxicity. Case: A 17-year-old female presented with an intentional thiocyanate ingestion. Her course was notable for delirium, wide complex tachycardia, and presumed seizure activity with concurrent lactatemia, acidemia, and narrowing of her arterio-venous oxygen gradient. She received lipid emulsion therapy (LET). While hemodialysis was considered, she recovered without additional treatment. After resolution of her critical illness, a serum cyanide concentration was 0.21 mcg/mL. She had laboratory testing notable for hyperchloremia, hypocalcemia, hypokalemia, and an elevated salicylate concentration attributed to interference by thiocyanate. The thiocyanate was eliminated via first-order kinetics with a half-life of 61.6 hours. Discussion: Thiocyanate poisoning may cause cardiac and neurologic toxicity. Laboratory evidence of impaired cellular respiration in this case suggests possible in vivo conversion to cyanide, however this is not proven. Cyanide antidotal treatment was not administered for this patient, however LET was given based on thiocyanate's lipophilicity. Hemodialysis is known to effectively remove thiocyanate from the blood, however the patient improved without it. The patient's laboratory derangements were due to thiocyanate interference with ion selective electrode and colorimetric analyzer technology. Conclusions: Thiocyanate can cause cardiac and neurologic toxicity, and interferes with several laboratory assays. Theoretically, LET and cyanide antidotal treatment may be useful, but this requires further investigation. Thiocyanate toxicity should be managed supportively, and hemodialysis may be used in severe cases. [ABSTRACT FROM AUTHOR]

Published
2022
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