BACKGROUND The coronavirus disease 2019(COVID-19)pandemic had a profound societal impact in the United States which was associated with a decrease in overall life expectancy and an increase in substance abuse and fire...BACKGROUND The coronavirus disease 2019(COVID-19)pandemic had a profound societal impact in the United States which was associated with a decrease in overall life expectancy and an increase in substance abuse and firearm injury.Our under-standing of changes in mortality trends during the pandemic and its effect on organ availability for transplantation is limited.AIM To examine the trends of substance abuse and firearm injury fatalities during COVID-19 and a potential correlation with organ transplantation.METHODS Crude rates of population-based deaths among adults(18-75 years)from firearm injury and substance abuse from the period of 2014-2021 were obtained from centers of disease control wide-ranging online data for epidemiologic research database.Crude rates of causes of donor(18-75 years)deaths from 2014-2021 were obtained from the united network for organ sharing database.RESULTS Average annual percentage change(AAPC)deaths among the United States population were 16.4%from substance abuse and 3.4%from firearm injury.AAPC in cause of death among organ donors was 10.9%from drug intoxication and 2.1%from firearm injury.There was a significant(P<0.001)and progressive increase in mortality from both causes during the pandemic(2020-2021)and significant correlation(P<0.001)between population and donor causes of death.COVID-19 exacerbated trends in substance abuse and firearm mortality with a consequent increase in organ donation from donors who died from these two causes.CONCLUSION Identifying the socioeconomic and regional disparities associated with increase in deaths from substance abuse and firearms can help guide post-pandemic healthcare policies and mitigate their impact on organ transplantation.展开更多
BACKGROUND Tramadol is a synthetic opioid analgesic commonly employed in postoperative pain control due to its moderate efficacy and comparatively favorable safety profile.Nonetheless,overdose can result in significan...BACKGROUND Tramadol is a synthetic opioid analgesic commonly employed in postoperative pain control due to its moderate efficacy and comparatively favorable safety profile.Nonetheless,overdose can result in significant adverse effects,notably central nervous system depression.This risk is amplified in individuals with chronic kidney disease(CKD),where reduced renal clearance may potentiate drug accumulation and toxicity.Elderly patients are particularly at risk owing to ageassociated alterations in pharmacokinetics and pharmacodynamics.We describe a case of tramadol overdose in a 77-year-old male with stage 3 CKD following total knee arthroplasty.CASE SUMMARY A 77-year-old male with diabetes mellitus and CKD stage 3 underwent elective right total knee arthroplasty for grade 4 osteoarthritis under spinal anesthesia.Preoperative evaluation revealed deranged renal function tests but no other significant abnormalities.Postoperative pain was managed with multimodal analgesics,including intravenous tramadol and a buprenorphine skin patch.On postoperative third day,the patient was found unconscious(Glasgow Coma Scale 8/15)with mild respiratory depression.Investigations ruled out stroke,pulmonary embolism,or other cardiopulmonary events.Elevated serum tramadol levels suggested opioid toxicity exacerbated by impaired renal clearance.The buprenorphine patch was removed,and diuresis was initiated.Supportive management,including prophylactic intubation,led to recovery of consciousness within 48 hours,and the patient was extubated and mobilized by postoperative sixth day.Pain control was maintained with oral paracetamol and pregabalin.The patient was discharged on postoperative tenth day in stable condition with improved pain scores and mobility.This case underscores the need for cautious use of tramadol in elderly patients with CKD due to impaired drug clearance and the potential for toxicity.It highlights the importance of close monitoring,judicious analgesic use,and prompt management of complications to ensure favorable postoperative outcomes in high-risk populations.CONCLUSION This case underscores the necessity for judicious tramadol administration in elderly patients with CKD,as diminished renal function markedly impairs drug clearance,predisposing to toxicity.Vigilant assessment of renal function and individualized dose adjustments are essential to mitigate the risk of adverse events in this demographic.Clinicians should maintain a heightened awareness of potential opioid toxicity in postoperative patients presenting with unexplained neurological manifestations.Timely identification and initiation of appropriate supportive measures are pivotal in achieving favorable clinical outcomes.展开更多
BACKGROUND Paracetamol overdose(POD)is the most common cause of acute hepatic failure(AHF)in the United Kingdom.Without urgent orthotopic liver transplant(OLT),mortality is high.Psychiatric assessment for transplant i...BACKGROUND Paracetamol overdose(POD)is the most common cause of acute hepatic failure(AHF)in the United Kingdom.Without urgent orthotopic liver transplant(OLT),mortality is high.Psychiatric assessment for transplant is time-pressured and often undertaken by psychiatrists without transplant experience.Assessors may identify absolute psychiatric contraindications(APCIs)precluding transplant in otherwise medically suitable patients.It is unknown how often this occurs.The combination of high but unknown mortality,time pressure,and relative inexperience is likely to provoke anxiety in assessors.This study hypothesised that the proportion of POD patients assessed for OLT who die because psychiatric contraindications preclude transplant would be small but not negligible.AIM To determine the proportion of patients with paracetamol-induced AHF,for whom psychiatric contraindications preclude transplantation,and the consequent mortality.METHODS This is an 18-year single-centre retrospective cohort study based in a national liver transplant centre.524 participants were identified from a departmental database and included if they had AHF from suspected POD and received a psychiatric assessment for OLT.For those who died before discharge,records were reviewed for medical and psychiatric contraindications to transplant,alongside age,sex,and primary psychiatric diagnosis.We calculated the proportion of patients assessed for whom APCIs precluded transplant,resulting in death.RESULTS Among 524 patients undergoing psychiatric assessment for OLT,there were 102 in-episode deaths(19.5%).APCIs were identified in 46 patients who were otherwise medically suitable for transplant and went on to die.This statistic represents 8.8%of the number of persons evaluated and 45%of the number of deaths.Within this subgroup,27(59%)were female,with a mean age of 44.6 years(ranging from 19-72 years).The most common primary psychiatric diagnosis was alcohol dependence syndrome,which accounted for 67%(n=31).CONCLUSION 8.8%of medically suitable patients with AHF following POD died with APCIs to transplant.This indicates a need for ongoing assessor training and support,and(inter)national comparisons of practice.展开更多
Rationale:Advances in sleep research have introduced medications like lemborexant,a dual orexin receptor antagonist.While effective for regulating sleep,overdoses are a concern,especially in suicide attempts.However,l...Rationale:Advances in sleep research have introduced medications like lemborexant,a dual orexin receptor antagonist.While effective for regulating sleep,overdoses are a concern,especially in suicide attempts.However,limited data exist on lemborexant overdose,prompting this case report to elucidate its clinical course.Patient’s Concern:A 91-year-old Japanese woman with multiple comorbidities,including insomnia and chronic kidney disease,was admitted after ingesting 315 mg of lemborexant in a suicide attempt.Diagnosis:Lemborexant overdose.Interventions:Supportive care with 500 mL of Ringer’s acetate solution at the emergency room.Outcomes:She gradually regained full consciousness with no residual deficits.Due to persistent suicidal ideation,she was transferred to a psychiatric hospital after seven days of supportive care.Lessons:A review of four lemborexant overdose cases managed at our hospital revealed that overdoses primarily induce altered consciousness and are unlikely to cause organ dysfunction.Supportive care is generally sufficient for management.However,given the limited data,further case accumulation is needed to enhance clinical understanding.展开更多
The United States is in the throes of a severe opioid overdose epidemic,primarily fueled by the pervasive use of fentanyl and the emerging threat of xylazine,a veterinary sedative often mixed with fentanyl.The high po...The United States is in the throes of a severe opioid overdose epidemic,primarily fueled by the pervasive use of fentanyl and the emerging threat of xylazine,a veterinary sedative often mixed with fentanyl.The high potency and long duration of fentanyl is compounded by the added risks from xylazine,heightening the lethal danger faced by opioid users.Measures such as enhanced surveillance,public awareness campaigns,and the distribution of fentanylxylazine test kits,and naloxone have been undertaken to mitigate this crisis.Fentanyl-related overdose deaths persist despite these efforts,partly due to inconsistent policies across states and resistance towards adopting harm reduction strategies.A multifaceted approach is imperative in effectively combating the opioid overdose epidemic.This approach should include expansion of treatment access,broadening the availability of medications for opioid use disorder,implementation of harm reduction strategies,and enaction of legislative reforms and diminishing stigma associated with opioid use disorder.展开更多
Polysubstance Abuse (PSA) greatly complicates an attempt to implicate a single drug as sole cause of an overdose death. Since PSA now occurs in the majority of cases of drug overdoses, many or most overdose deaths are...Polysubstance Abuse (PSA) greatly complicates an attempt to implicate a single drug as sole cause of an overdose death. Since PSA now occurs in the majority of cases of drug overdoses, many or most overdose deaths are polysubstance overdose deaths. And since many of the substances involved in a polysubstance Overdose Death (POD) are Central Nervous System (CNS) depressants, many of which can cause overdose death themselves, or synergistically with opioids, it is somewhat puzzling that prescription opioids have been singled out as the cause of these deaths—without reference to PSA. This is particularly puzzling in light of the fact that the issues of PSA and POD have been recognized and discussed in the literature since at least the 1960’s and before. We therefore here consider the question: are we facing an “opioid” crisis or, instead, a “polysubstance crisis”? And we wonder if the issue has been over-simplified, to the detriment of the individuals affected, and to society more broadly. There is a need for an “agnostic” respiratory stimulant that can reverse polysubstance-induced respiratory depression.展开更多
Polysubstance (combinations of substances) abuse and overdose deaths now surpass mono-substance abuse and overdose deaths. Several international and governmental organizations such as the WHO (World Health Organizatio...Polysubstance (combinations of substances) abuse and overdose deaths now surpass mono-substance abuse and overdose deaths. Several international and governmental organizations such as the WHO (World Health Organization), CDC (Centers for Disease Control and Prevention), several of the Institutes of the NIH (National Institutes of Health), Regulators, and Enforcement Agencies, among others, track and provide a valuable source of statistical information about drug (prescription and illicit) (mis)use and overdose. The information is disseminated free to stakeholders and the general public for use. Although the numeric presentations of the data are helpful and adequate for professionals, the non-expert and the visual learner often find visual representation more clear and more compelling. With this in mind, the aim of this study was to present polysubstance use and overdose using visual maps of the available data. This article considers the opioids.展开更多
Rationale:Delayed post-hypoxic leukoencephalopathy(DPHL)is usually an overlooked condition,which arises as a result of a multitude of reversible and irreversible conditions.Patient’s Concern:A 50-year-old female with...Rationale:Delayed post-hypoxic leukoencephalopathy(DPHL)is usually an overlooked condition,which arises as a result of a multitude of reversible and irreversible conditions.Patient’s Concern:A 50-year-old female with a history of epilepsy,who developed DPHL 12 days after respiratory failure secondary to barbiturate toxicity.Diagnosis:DPHL on magnetic resonance imaging of the brain.Interventions:Mechanical ventilation was initiated for respiratory failure and hemodialysis for barbiturate toxicity.Outcomes:The patient developed akinetic mutism due to infirmity and had a residual disability,which led to permanent dependency.Lessons:The diagnosis of DPHL is often delayed or missed,given the rarity of this condition and its inconsistent clinical symptomatology.Diagnostic delay can be avoided by early recognition of the classical“delayed onset”symptoms.展开更多
Dear editor, We report a case of a 47-year-old female who presented with a toxic bupropion ingestion leading to cardiac arrest. She initially exhibited a loss of brainstem reflexes in conjunction with burst-suppressio...Dear editor, We report a case of a 47-year-old female who presented with a toxic bupropion ingestion leading to cardiac arrest. She initially exhibited a loss of brainstem reflexes in conjunction with burst-suppression pattern on EEG. Burst suppression is an EEG waveform pattern of alternating isoelectric suppressions and high voltage bursts, Our patient ultimately made a full neurologic recovery a few days later. While there are two other cases in the literature of bupropion overdose resulting in EEG burst-suppression and loss of brainstem reflexes, we believe this is the only reported adult case complicated by cardiac arrest.展开更多
A case is presented of a serious, potentially life-threatening intravenous acetaminophen overdose in a 3-month-old (40 weeks’ post menstrual age),2.3 kgbaby girl. The neonate was scheduled for urgent laser therapy fo...A case is presented of a serious, potentially life-threatening intravenous acetaminophen overdose in a 3-month-old (40 weeks’ post menstrual age),2.3 kgbaby girl. The neonate was scheduled for urgent laser therapy for retinopathy of prematurity. Instead of an intended intravenous Hartmann’s solution bolus of 10 ml·kgˉ1, the neonate received a 17 ml bolus of correctly labelled intravenous 1% acetaminophen. The National Poisons Bureau was immediately contacted for advice and in the absence of data suggested a treatment with N-acetylcysteine for a 24-hour period. Baseline blood samples for clotting, liver function, urea and electrolytes, full blood count and plasma acetaminophen concentration were taken 30 min, 8.25 h, 12.5 h, 18.5 h and 120 h after the overdose. Acetaminophen concentration was 78 mg·Lˉ1 at 30 min, but it was undetectable at any other time. Using a recent and complete PK-PD dataset we are able to show that the measured plasma acetaminophen concentration fits well on PK estimates for acetaminophen in this neonate. The non-detectable (low) plasma acetaminophen concentration at >8 h is also consistent with this model, especially if clearance is slightly increased in the premature nursery graduate. Medical errors are rarely the fault of an individual and they are often due to a combination of factors. Contributing factors, in this case, are described under the following headings: Catalyst event, system fault, loss of situational awareness, and human error.展开更多
A paucity of literature exists linking acute extremity compartment syndrome associated with cocaine or olanzapine overdose. LJ, a 38-year male, was initially seen at an outside hospital for acute encephalopathy and le...A paucity of literature exists linking acute extremity compartment syndrome associated with cocaine or olanzapine overdose. LJ, a 38-year male, was initially seen at an outside hospital for acute encephalopathy and left lower extremity swelling shortly after cocaine and suspected olanzapine overdose. On presentation, totalcreatinine kinase levels were >1000 units/liter but quickly rose to 23,000 units/liter after 12 hours. He was transferred to a tertiary care center for surgical evaluation. Upon the exam, it was quickly determined that he had compartment syndrome and he was urgently taken to the operating room for a four-compartment lower extremity fasciotomy. Acute compartment syndrome is a limb threatening condition generally diagnosed clinically. Cocaine, a potent vasoconstrictor, is widely reported to cause rhabdomyolysis from ischemia of skeletal muscle tissue and direct toxicity to myocytes resulting in leakage of creatinine kinase. Other complications including cardiovascular, respiratory, neurological, and gastrointestinal disturbances have also been well documented. Olanzapine, an atypical antipsychotic, has also been reported to cause rhabdomyolysis. However, myositis with lower extremity compartment syndrome is a rare occurrence and requires quick diagnosis and aggressive treatment in order to achieve limb salvage. The potential causality of compartment syndrome from either cocaine, olanzapine, or both will be examined in this case report.展开更多
A 22-year-old pregnant female was transferred to the emergency department having ingested a bottle of iron-containing prenatal vitamins, ondansetron (Zofran?) tablets and alcohol. The patient was hemodynamically stabl...A 22-year-old pregnant female was transferred to the emergency department having ingested a bottle of iron-containing prenatal vitamins, ondansetron (Zofran?) tablets and alcohol. The patient was hemodynamically stable but suffered from intense bouts of brown, sandy emesis for the first few hours. Investigation revealed the patient ingested 13.57 mg/kg of elemental iron. Due to the initial iron level, history and presentation time whole bowel irrigation was initiated with polyethylene glycol solution. Acute iron toxicity in pregnancy is a medical emergency that can result in multisystem organ failure leading to maternal death and potential fetal demise. High maternal serum iron loads do not affect the developing fetus and are not associated with fetal malformations;however advanced poisoning can lead to maternal death, spontaneous abortions or preterm emergency deliveries. Initial treatment strategies may include whole bowel irrigation using polyethylene glycol electrolyte lavage solution and deferoxamine treatment along with necessary supportive care management. Despite concerns of teratogenicity deferoxamine does not cross the placenta and is regarded as safe for use during pregnancy. Maternal resuscitation must always be the primary objective in acute iron overdoses and, therefore such concern should not delay clinically indicated maternal treatment.展开更多
Valproic acid is used in the treatment of multiple disorders. Adverse effects from valproic acid include hepatotoxicity, hypotension, metabolic acidosis, and decreased mental status. Valproic acid also causes hyperamm...Valproic acid is used in the treatment of multiple disorders. Adverse effects from valproic acid include hepatotoxicity, hypotension, metabolic acidosis, and decreased mental status. Valproic acid also causes hyperammonemia. Many physicians assume that this is due to a supratherapeutic valproic acid concentration;when in fact, it can occur with therapeutic valproic acid concentrations. This is because the hyperammonemia may be related to carnitine deficiency and disruption of the urea cycle, which can both occur with therapeutic valproic acid concentrations. We report a patient presented to the emergency department with alteration of mental status after ingesting valproic acid for recreational purposes, who developed hyperammonemia with a therapeutic valproic acid concentration.展开更多
The antidepressant venlafaxine in overdose can lead to serotonin syndrome, seizures, QTc interval prolongation and can increase the risk of cardiac arrhythmias. It has been reported to be more toxic in overdose than o...The antidepressant venlafaxine in overdose can lead to serotonin syndrome, seizures, QTc interval prolongation and can increase the risk of cardiac arrhythmias. It has been reported to be more toxic in overdose than other new antidepressants. We report a case of venlafaxine intoxication with a venlafaxine/O-desmethylvenlafaxine serum level of 2861/2670 ng/mL 22 h after ingestion. This is one of the so far highest survived venlafaxin serum levels. In contrast to other reported survived venlafaxin overdoses with high serum levels no clinical signs of intoxication were observed in our case. So venlafaxine overdose not necessarily leads to life-threatening signs of intoxication.展开更多
We report a near fatal case of paediatric amitriptyline overdose including a series of ECGs demonstrating the effects of sodium bicarbonate therapy on cardio-toxicity. We briefly discuss the role of sodium to countera...We report a near fatal case of paediatric amitriptyline overdose including a series of ECGs demonstrating the effects of sodium bicarbonate therapy on cardio-toxicity. We briefly discuss the role of sodium to counteract the sodium channel blockade of tricyclic antidepressants and discuss the possible utility of lipid emulsion therapy in such cases.展开更多
<span style="font-family:Verdana;">The </span><span style="font-family:Verdana;">“</span><span style="font-family:Verdana;">opioid crisis</span><sp...<span style="font-family:Verdana;">The </span><span style="font-family:Verdana;">“</span><span style="font-family:Verdana;">opioid crisis</span><span style="font-family:Verdana;">”</span><span style="font-family:""><span style="font-family:Verdana;"> has had a tremendous impact not only on its victims, but also on the practice of medicine, pain patients, and society in general. Unfortunately, efforts to “stem the tide” have not been successful at reducing overdose deaths. Counterbalancing the many ardent efforts to eliminate overdose deaths (such as the current widespread availability and use of opioid-receptor antagonists such as naloxone) is influx of the illicit fentanoids (</span><i><span style="font-family:Verdana;">i.e</span></i><span style="font-family:Verdana;">., fentanyl and analogs). In addition to their high-potency, the fentanoids differ in surprising ways from more “traditional” opioids such as morphine and heroin. This uniqueness contributes to a reduced effectiveness of opioid receptor antagonists in the treatment of opioid overdose. Further greatly complicating overdose treatment is polysubstance abuse (e.g., an opioid plus a benzodiaze</span><span style="font-family:Verdana;">pine). The non-opioid in the combination is not responsive to an opio</span><span style="font-family:Verdana;">id-recep</span></span><span style="font-family:Verdana;">- </span><span style="font-family:""><span style="font-family:Verdana;">tor antagonist, which imparts additional challenges. Thus, the new reality in</span><span style="font-family:Verdana;">troduces complications that negatively impact efforts to reverse </span></span><span style="font-family:Verdana;">“</span><span style="font-family:Verdana;">opioid</span><span style="font-family:Verdana;">”</span><span style="font-family:""><span style="font-family:Verdana;"> overdose. New approaches to improve outcomes in individuals who experience </span><span style="font-family:Verdana;">respiratory depression due to fentanoid-induced or polysubstance-induced</span><span style="font-family:Verdana;"> over</span></span><span style="font-family:Verdana;">- </span><span style="font-family:Verdana;">dose are needed. Approaches that harmonize with the new reality, perhaps something like a non-opioid </span><span style="font-family:Verdana;">“</span><span style="font-family:Verdana;">agnostic</span><span style="font-family:Verdana;">”</span><span style="font-family:Verdana;"> pharmacologic ventilatory stimulant, would provide a welcome addition to the current choices.</span>展开更多
The purpose of this research was to investigate the manner of deaths in Marion County, throughout the years of 2018 to 2021 to see if there were any correlative increases in homicide, suicide, natural, accidental, or ...The purpose of this research was to investigate the manner of deaths in Marion County, throughout the years of 2018 to 2021 to see if there were any correlative increases in homicide, suicide, natural, accidental, or drug overdose related deaths. We surveyed the incidence of all deaths that occurred from 2018 through 2021 which came through the Marion County Coroner’s Office, Indiana. The data was then divided into two halves. According to the data, the leading manner of death in the first half and second half was accidental. This study revealed a total of 8732 cases: 3817 of them were observed to be accidental, 3092 natural, 956 homicide, 689 suicide, and 178 were undetermined. There were initially 318 drug overdose related deaths in 2018 and they increased to 2163 by 2021. In 2018, the number of deaths due to fentanyl related overdoses increased from 195 to 799 in 2021. This research will contribute to the forensic science field by providing information about the manner of death and fentanyl trends in Marion County over the last four years.展开更多
Abuse of drug substances and resultant overdose deaths are no longer very straightforward—viz., attributable to a single chemical entity of known purity. The reality is that most overdose deaths involve polysubstance...Abuse of drug substances and resultant overdose deaths are no longer very straightforward—viz., attributable to a single chemical entity of known purity. The reality is that most overdose deaths involve polysubstance use (i.e., the use of combinations of substances). Further, the combinations are often of unknown purity, and even of unknown composition. Overdose deaths are at all-time highs. The depressing statistics are monitored and reported by several international and governmental organizations such as the WHO (World Health Organization), CDC (Centers for Disease Control and Prevention), several Institutes of the NIH (National Institutes of Health), Regulators, and Enforcement Agencies (e.g., DEA). The information is disseminated for free for review and use. But it is our observation that although numeric presentation is helpful and adequate for professionals, the non-expert and the visual learner often find a visual representation clearer and compelling. With this in mind, we present the “gestalt” of polysubstance use and overdose using available maps of the data. The previous article in the series considered the opioids. This one considers amphetamines and cocaine, and places the rise in opioid-associated overdose deaths in the context of other abused drugs.展开更多
According to the NationalHeart,Lung,and Blood Institute(2023),[1]out-of-hospital cardiac arrests(OHCA)claim more than 350,000 lives every year.In parallel,and considering a timeframe starting in 1999,a continuous incr...According to the NationalHeart,Lung,and Blood Institute(2023),[1]out-of-hospital cardiac arrests(OHCA)claim more than 350,000 lives every year.In parallel,and considering a timeframe starting in 1999,a continuous increase in the number of deaths due to opioid overdose or poisoning(OOP)events is found[2](Fig.1).展开更多
Background:A lack of standardization in death investigation procedures is associated with a significant undercounting of opioid-related overdoses in the United States.Because overdose fatality statistics are often use...Background:A lack of standardization in death investigation procedures is associated with a significant undercounting of opioid-related overdoses in the United States.Because overdose fatality statistics are often used to allocate federal and state funding,inaccuracies can worsen the gap between actual and needed death investigation resources.Aims and Objectives:This case study examines Indiana’s legislative efforts to improve toxicology surveillance and its impact on county coroners.Materials and Methods:First,the proportion of unspecified overdose deaths were examined by comparing Indiana and the United States using CDC WONDER data from 2016-2020.Second,we surveyed Indiana coroners’offices on their perceptions of the law’s requirements,available resources,and barriers to compliance.Results:We first describe fatal overdose trends in Indiana from 2016 to 2020,noting its overall improvement in identifying opioid-related deaths.Next,we present results from a survey of 30 coroners’offices,focusing on their perceptions of the requirements,available resources,and barriers to compliance.Finally,we consider successes and areas of improvement.Conclusion:This case study highlights the importance of state efforts to improve toxicology surveillance,especially in decentralized county coroner systems.展开更多
文摘BACKGROUND The coronavirus disease 2019(COVID-19)pandemic had a profound societal impact in the United States which was associated with a decrease in overall life expectancy and an increase in substance abuse and firearm injury.Our under-standing of changes in mortality trends during the pandemic and its effect on organ availability for transplantation is limited.AIM To examine the trends of substance abuse and firearm injury fatalities during COVID-19 and a potential correlation with organ transplantation.METHODS Crude rates of population-based deaths among adults(18-75 years)from firearm injury and substance abuse from the period of 2014-2021 were obtained from centers of disease control wide-ranging online data for epidemiologic research database.Crude rates of causes of donor(18-75 years)deaths from 2014-2021 were obtained from the united network for organ sharing database.RESULTS Average annual percentage change(AAPC)deaths among the United States population were 16.4%from substance abuse and 3.4%from firearm injury.AAPC in cause of death among organ donors was 10.9%from drug intoxication and 2.1%from firearm injury.There was a significant(P<0.001)and progressive increase in mortality from both causes during the pandemic(2020-2021)and significant correlation(P<0.001)between population and donor causes of death.COVID-19 exacerbated trends in substance abuse and firearm mortality with a consequent increase in organ donation from donors who died from these two causes.CONCLUSION Identifying the socioeconomic and regional disparities associated with increase in deaths from substance abuse and firearms can help guide post-pandemic healthcare policies and mitigate their impact on organ transplantation.
文摘BACKGROUND Tramadol is a synthetic opioid analgesic commonly employed in postoperative pain control due to its moderate efficacy and comparatively favorable safety profile.Nonetheless,overdose can result in significant adverse effects,notably central nervous system depression.This risk is amplified in individuals with chronic kidney disease(CKD),where reduced renal clearance may potentiate drug accumulation and toxicity.Elderly patients are particularly at risk owing to ageassociated alterations in pharmacokinetics and pharmacodynamics.We describe a case of tramadol overdose in a 77-year-old male with stage 3 CKD following total knee arthroplasty.CASE SUMMARY A 77-year-old male with diabetes mellitus and CKD stage 3 underwent elective right total knee arthroplasty for grade 4 osteoarthritis under spinal anesthesia.Preoperative evaluation revealed deranged renal function tests but no other significant abnormalities.Postoperative pain was managed with multimodal analgesics,including intravenous tramadol and a buprenorphine skin patch.On postoperative third day,the patient was found unconscious(Glasgow Coma Scale 8/15)with mild respiratory depression.Investigations ruled out stroke,pulmonary embolism,or other cardiopulmonary events.Elevated serum tramadol levels suggested opioid toxicity exacerbated by impaired renal clearance.The buprenorphine patch was removed,and diuresis was initiated.Supportive management,including prophylactic intubation,led to recovery of consciousness within 48 hours,and the patient was extubated and mobilized by postoperative sixth day.Pain control was maintained with oral paracetamol and pregabalin.The patient was discharged on postoperative tenth day in stable condition with improved pain scores and mobility.This case underscores the need for cautious use of tramadol in elderly patients with CKD due to impaired drug clearance and the potential for toxicity.It highlights the importance of close monitoring,judicious analgesic use,and prompt management of complications to ensure favorable postoperative outcomes in high-risk populations.CONCLUSION This case underscores the necessity for judicious tramadol administration in elderly patients with CKD,as diminished renal function markedly impairs drug clearance,predisposing to toxicity.Vigilant assessment of renal function and individualized dose adjustments are essential to mitigate the risk of adverse events in this demographic.Clinicians should maintain a heightened awareness of potential opioid toxicity in postoperative patients presenting with unexplained neurological manifestations.Timely identification and initiation of appropriate supportive measures are pivotal in achieving favorable clinical outcomes.
文摘BACKGROUND Paracetamol overdose(POD)is the most common cause of acute hepatic failure(AHF)in the United Kingdom.Without urgent orthotopic liver transplant(OLT),mortality is high.Psychiatric assessment for transplant is time-pressured and often undertaken by psychiatrists without transplant experience.Assessors may identify absolute psychiatric contraindications(APCIs)precluding transplant in otherwise medically suitable patients.It is unknown how often this occurs.The combination of high but unknown mortality,time pressure,and relative inexperience is likely to provoke anxiety in assessors.This study hypothesised that the proportion of POD patients assessed for OLT who die because psychiatric contraindications preclude transplant would be small but not negligible.AIM To determine the proportion of patients with paracetamol-induced AHF,for whom psychiatric contraindications preclude transplantation,and the consequent mortality.METHODS This is an 18-year single-centre retrospective cohort study based in a national liver transplant centre.524 participants were identified from a departmental database and included if they had AHF from suspected POD and received a psychiatric assessment for OLT.For those who died before discharge,records were reviewed for medical and psychiatric contraindications to transplant,alongside age,sex,and primary psychiatric diagnosis.We calculated the proportion of patients assessed for whom APCIs precluded transplant,resulting in death.RESULTS Among 524 patients undergoing psychiatric assessment for OLT,there were 102 in-episode deaths(19.5%).APCIs were identified in 46 patients who were otherwise medically suitable for transplant and went on to die.This statistic represents 8.8%of the number of persons evaluated and 45%of the number of deaths.Within this subgroup,27(59%)were female,with a mean age of 44.6 years(ranging from 19-72 years).The most common primary psychiatric diagnosis was alcohol dependence syndrome,which accounted for 67%(n=31).CONCLUSION 8.8%of medically suitable patients with AHF following POD died with APCIs to transplant.This indicates a need for ongoing assessor training and support,and(inter)national comparisons of practice.
文摘Rationale:Advances in sleep research have introduced medications like lemborexant,a dual orexin receptor antagonist.While effective for regulating sleep,overdoses are a concern,especially in suicide attempts.However,limited data exist on lemborexant overdose,prompting this case report to elucidate its clinical course.Patient’s Concern:A 91-year-old Japanese woman with multiple comorbidities,including insomnia and chronic kidney disease,was admitted after ingesting 315 mg of lemborexant in a suicide attempt.Diagnosis:Lemborexant overdose.Interventions:Supportive care with 500 mL of Ringer’s acetate solution at the emergency room.Outcomes:She gradually regained full consciousness with no residual deficits.Due to persistent suicidal ideation,she was transferred to a psychiatric hospital after seven days of supportive care.Lessons:A review of four lemborexant overdose cases managed at our hospital revealed that overdoses primarily induce altered consciousness and are unlikely to cause organ dysfunction.Supportive care is generally sufficient for management.However,given the limited data,further case accumulation is needed to enhance clinical understanding.
文摘The United States is in the throes of a severe opioid overdose epidemic,primarily fueled by the pervasive use of fentanyl and the emerging threat of xylazine,a veterinary sedative often mixed with fentanyl.The high potency and long duration of fentanyl is compounded by the added risks from xylazine,heightening the lethal danger faced by opioid users.Measures such as enhanced surveillance,public awareness campaigns,and the distribution of fentanylxylazine test kits,and naloxone have been undertaken to mitigate this crisis.Fentanyl-related overdose deaths persist despite these efforts,partly due to inconsistent policies across states and resistance towards adopting harm reduction strategies.A multifaceted approach is imperative in effectively combating the opioid overdose epidemic.This approach should include expansion of treatment access,broadening the availability of medications for opioid use disorder,implementation of harm reduction strategies,and enaction of legislative reforms and diminishing stigma associated with opioid use disorder.
文摘Polysubstance Abuse (PSA) greatly complicates an attempt to implicate a single drug as sole cause of an overdose death. Since PSA now occurs in the majority of cases of drug overdoses, many or most overdose deaths are polysubstance overdose deaths. And since many of the substances involved in a polysubstance Overdose Death (POD) are Central Nervous System (CNS) depressants, many of which can cause overdose death themselves, or synergistically with opioids, it is somewhat puzzling that prescription opioids have been singled out as the cause of these deaths—without reference to PSA. This is particularly puzzling in light of the fact that the issues of PSA and POD have been recognized and discussed in the literature since at least the 1960’s and before. We therefore here consider the question: are we facing an “opioid” crisis or, instead, a “polysubstance crisis”? And we wonder if the issue has been over-simplified, to the detriment of the individuals affected, and to society more broadly. There is a need for an “agnostic” respiratory stimulant that can reverse polysubstance-induced respiratory depression.
文摘Polysubstance (combinations of substances) abuse and overdose deaths now surpass mono-substance abuse and overdose deaths. Several international and governmental organizations such as the WHO (World Health Organization), CDC (Centers for Disease Control and Prevention), several of the Institutes of the NIH (National Institutes of Health), Regulators, and Enforcement Agencies, among others, track and provide a valuable source of statistical information about drug (prescription and illicit) (mis)use and overdose. The information is disseminated free to stakeholders and the general public for use. Although the numeric presentations of the data are helpful and adequate for professionals, the non-expert and the visual learner often find visual representation more clear and more compelling. With this in mind, the aim of this study was to present polysubstance use and overdose using visual maps of the available data. This article considers the opioids.
文摘Rationale:Delayed post-hypoxic leukoencephalopathy(DPHL)is usually an overlooked condition,which arises as a result of a multitude of reversible and irreversible conditions.Patient’s Concern:A 50-year-old female with a history of epilepsy,who developed DPHL 12 days after respiratory failure secondary to barbiturate toxicity.Diagnosis:DPHL on magnetic resonance imaging of the brain.Interventions:Mechanical ventilation was initiated for respiratory failure and hemodialysis for barbiturate toxicity.Outcomes:The patient developed akinetic mutism due to infirmity and had a residual disability,which led to permanent dependency.Lessons:The diagnosis of DPHL is often delayed or missed,given the rarity of this condition and its inconsistent clinical symptomatology.Diagnostic delay can be avoided by early recognition of the classical“delayed onset”symptoms.
文摘Dear editor, We report a case of a 47-year-old female who presented with a toxic bupropion ingestion leading to cardiac arrest. She initially exhibited a loss of brainstem reflexes in conjunction with burst-suppression pattern on EEG. Burst suppression is an EEG waveform pattern of alternating isoelectric suppressions and high voltage bursts, Our patient ultimately made a full neurologic recovery a few days later. While there are two other cases in the literature of bupropion overdose resulting in EEG burst-suppression and loss of brainstem reflexes, we believe this is the only reported adult case complicated by cardiac arrest.
文摘A case is presented of a serious, potentially life-threatening intravenous acetaminophen overdose in a 3-month-old (40 weeks’ post menstrual age),2.3 kgbaby girl. The neonate was scheduled for urgent laser therapy for retinopathy of prematurity. Instead of an intended intravenous Hartmann’s solution bolus of 10 ml·kgˉ1, the neonate received a 17 ml bolus of correctly labelled intravenous 1% acetaminophen. The National Poisons Bureau was immediately contacted for advice and in the absence of data suggested a treatment with N-acetylcysteine for a 24-hour period. Baseline blood samples for clotting, liver function, urea and electrolytes, full blood count and plasma acetaminophen concentration were taken 30 min, 8.25 h, 12.5 h, 18.5 h and 120 h after the overdose. Acetaminophen concentration was 78 mg·Lˉ1 at 30 min, but it was undetectable at any other time. Using a recent and complete PK-PD dataset we are able to show that the measured plasma acetaminophen concentration fits well on PK estimates for acetaminophen in this neonate. The non-detectable (low) plasma acetaminophen concentration at >8 h is also consistent with this model, especially if clearance is slightly increased in the premature nursery graduate. Medical errors are rarely the fault of an individual and they are often due to a combination of factors. Contributing factors, in this case, are described under the following headings: Catalyst event, system fault, loss of situational awareness, and human error.
文摘A paucity of literature exists linking acute extremity compartment syndrome associated with cocaine or olanzapine overdose. LJ, a 38-year male, was initially seen at an outside hospital for acute encephalopathy and left lower extremity swelling shortly after cocaine and suspected olanzapine overdose. On presentation, totalcreatinine kinase levels were >1000 units/liter but quickly rose to 23,000 units/liter after 12 hours. He was transferred to a tertiary care center for surgical evaluation. Upon the exam, it was quickly determined that he had compartment syndrome and he was urgently taken to the operating room for a four-compartment lower extremity fasciotomy. Acute compartment syndrome is a limb threatening condition generally diagnosed clinically. Cocaine, a potent vasoconstrictor, is widely reported to cause rhabdomyolysis from ischemia of skeletal muscle tissue and direct toxicity to myocytes resulting in leakage of creatinine kinase. Other complications including cardiovascular, respiratory, neurological, and gastrointestinal disturbances have also been well documented. Olanzapine, an atypical antipsychotic, has also been reported to cause rhabdomyolysis. However, myositis with lower extremity compartment syndrome is a rare occurrence and requires quick diagnosis and aggressive treatment in order to achieve limb salvage. The potential causality of compartment syndrome from either cocaine, olanzapine, or both will be examined in this case report.
文摘A 22-year-old pregnant female was transferred to the emergency department having ingested a bottle of iron-containing prenatal vitamins, ondansetron (Zofran?) tablets and alcohol. The patient was hemodynamically stable but suffered from intense bouts of brown, sandy emesis for the first few hours. Investigation revealed the patient ingested 13.57 mg/kg of elemental iron. Due to the initial iron level, history and presentation time whole bowel irrigation was initiated with polyethylene glycol solution. Acute iron toxicity in pregnancy is a medical emergency that can result in multisystem organ failure leading to maternal death and potential fetal demise. High maternal serum iron loads do not affect the developing fetus and are not associated with fetal malformations;however advanced poisoning can lead to maternal death, spontaneous abortions or preterm emergency deliveries. Initial treatment strategies may include whole bowel irrigation using polyethylene glycol electrolyte lavage solution and deferoxamine treatment along with necessary supportive care management. Despite concerns of teratogenicity deferoxamine does not cross the placenta and is regarded as safe for use during pregnancy. Maternal resuscitation must always be the primary objective in acute iron overdoses and, therefore such concern should not delay clinically indicated maternal treatment.
文摘Valproic acid is used in the treatment of multiple disorders. Adverse effects from valproic acid include hepatotoxicity, hypotension, metabolic acidosis, and decreased mental status. Valproic acid also causes hyperammonemia. Many physicians assume that this is due to a supratherapeutic valproic acid concentration;when in fact, it can occur with therapeutic valproic acid concentrations. This is because the hyperammonemia may be related to carnitine deficiency and disruption of the urea cycle, which can both occur with therapeutic valproic acid concentrations. We report a patient presented to the emergency department with alteration of mental status after ingesting valproic acid for recreational purposes, who developed hyperammonemia with a therapeutic valproic acid concentration.
文摘The antidepressant venlafaxine in overdose can lead to serotonin syndrome, seizures, QTc interval prolongation and can increase the risk of cardiac arrhythmias. It has been reported to be more toxic in overdose than other new antidepressants. We report a case of venlafaxine intoxication with a venlafaxine/O-desmethylvenlafaxine serum level of 2861/2670 ng/mL 22 h after ingestion. This is one of the so far highest survived venlafaxin serum levels. In contrast to other reported survived venlafaxin overdoses with high serum levels no clinical signs of intoxication were observed in our case. So venlafaxine overdose not necessarily leads to life-threatening signs of intoxication.
文摘We report a near fatal case of paediatric amitriptyline overdose including a series of ECGs demonstrating the effects of sodium bicarbonate therapy on cardio-toxicity. We briefly discuss the role of sodium to counteract the sodium channel blockade of tricyclic antidepressants and discuss the possible utility of lipid emulsion therapy in such cases.
文摘<span style="font-family:Verdana;">The </span><span style="font-family:Verdana;">“</span><span style="font-family:Verdana;">opioid crisis</span><span style="font-family:Verdana;">”</span><span style="font-family:""><span style="font-family:Verdana;"> has had a tremendous impact not only on its victims, but also on the practice of medicine, pain patients, and society in general. Unfortunately, efforts to “stem the tide” have not been successful at reducing overdose deaths. Counterbalancing the many ardent efforts to eliminate overdose deaths (such as the current widespread availability and use of opioid-receptor antagonists such as naloxone) is influx of the illicit fentanoids (</span><i><span style="font-family:Verdana;">i.e</span></i><span style="font-family:Verdana;">., fentanyl and analogs). In addition to their high-potency, the fentanoids differ in surprising ways from more “traditional” opioids such as morphine and heroin. This uniqueness contributes to a reduced effectiveness of opioid receptor antagonists in the treatment of opioid overdose. Further greatly complicating overdose treatment is polysubstance abuse (e.g., an opioid plus a benzodiaze</span><span style="font-family:Verdana;">pine). The non-opioid in the combination is not responsive to an opio</span><span style="font-family:Verdana;">id-recep</span></span><span style="font-family:Verdana;">- </span><span style="font-family:""><span style="font-family:Verdana;">tor antagonist, which imparts additional challenges. Thus, the new reality in</span><span style="font-family:Verdana;">troduces complications that negatively impact efforts to reverse </span></span><span style="font-family:Verdana;">“</span><span style="font-family:Verdana;">opioid</span><span style="font-family:Verdana;">”</span><span style="font-family:""><span style="font-family:Verdana;"> overdose. New approaches to improve outcomes in individuals who experience </span><span style="font-family:Verdana;">respiratory depression due to fentanoid-induced or polysubstance-induced</span><span style="font-family:Verdana;"> over</span></span><span style="font-family:Verdana;">- </span><span style="font-family:Verdana;">dose are needed. Approaches that harmonize with the new reality, perhaps something like a non-opioid </span><span style="font-family:Verdana;">“</span><span style="font-family:Verdana;">agnostic</span><span style="font-family:Verdana;">”</span><span style="font-family:Verdana;"> pharmacologic ventilatory stimulant, would provide a welcome addition to the current choices.</span>
文摘The purpose of this research was to investigate the manner of deaths in Marion County, throughout the years of 2018 to 2021 to see if there were any correlative increases in homicide, suicide, natural, accidental, or drug overdose related deaths. We surveyed the incidence of all deaths that occurred from 2018 through 2021 which came through the Marion County Coroner’s Office, Indiana. The data was then divided into two halves. According to the data, the leading manner of death in the first half and second half was accidental. This study revealed a total of 8732 cases: 3817 of them were observed to be accidental, 3092 natural, 956 homicide, 689 suicide, and 178 were undetermined. There were initially 318 drug overdose related deaths in 2018 and they increased to 2163 by 2021. In 2018, the number of deaths due to fentanyl related overdoses increased from 195 to 799 in 2021. This research will contribute to the forensic science field by providing information about the manner of death and fentanyl trends in Marion County over the last four years.
文摘Abuse of drug substances and resultant overdose deaths are no longer very straightforward—viz., attributable to a single chemical entity of known purity. The reality is that most overdose deaths involve polysubstance use (i.e., the use of combinations of substances). Further, the combinations are often of unknown purity, and even of unknown composition. Overdose deaths are at all-time highs. The depressing statistics are monitored and reported by several international and governmental organizations such as the WHO (World Health Organization), CDC (Centers for Disease Control and Prevention), several Institutes of the NIH (National Institutes of Health), Regulators, and Enforcement Agencies (e.g., DEA). The information is disseminated for free for review and use. But it is our observation that although numeric presentation is helpful and adequate for professionals, the non-expert and the visual learner often find a visual representation clearer and compelling. With this in mind, we present the “gestalt” of polysubstance use and overdose using available maps of the data. The previous article in the series considered the opioids. This one considers amphetamines and cocaine, and places the rise in opioid-associated overdose deaths in the context of other abused drugs.
文摘According to the NationalHeart,Lung,and Blood Institute(2023),[1]out-of-hospital cardiac arrests(OHCA)claim more than 350,000 lives every year.In parallel,and considering a timeframe starting in 1999,a continuous increase in the number of deaths due to opioid overdose or poisoning(OOP)events is found[2](Fig.1).
基金supported by funding from the ONDCP,HIDTA Program(CFDA#95.001).
文摘Background:A lack of standardization in death investigation procedures is associated with a significant undercounting of opioid-related overdoses in the United States.Because overdose fatality statistics are often used to allocate federal and state funding,inaccuracies can worsen the gap between actual and needed death investigation resources.Aims and Objectives:This case study examines Indiana’s legislative efforts to improve toxicology surveillance and its impact on county coroners.Materials and Methods:First,the proportion of unspecified overdose deaths were examined by comparing Indiana and the United States using CDC WONDER data from 2016-2020.Second,we surveyed Indiana coroners’offices on their perceptions of the law’s requirements,available resources,and barriers to compliance.Results:We first describe fatal overdose trends in Indiana from 2016 to 2020,noting its overall improvement in identifying opioid-related deaths.Next,we present results from a survey of 30 coroners’offices,focusing on their perceptions of the requirements,available resources,and barriers to compliance.Finally,we consider successes and areas of improvement.Conclusion:This case study highlights the importance of state efforts to improve toxicology surveillance,especially in decentralized county coroner systems.
