Protonitazene detection in two cases of opioid toxicity following the use of tetrahydrocannabinol vape products in Australia.

INTRODUCTION: Protonitazene is an opioid belonging to the 2-benzylbenzimidazole structural class. We describe two cases of opioid toxicity involving the reported inhalation of a delta-9-tetrahydrocannabinol vape product in which protonitazene was detected. CASE REPORTS: Case 1 was a young male found unconscious after the reported use of a delta-9-tetrahydrocannabinol vape. He suffered two subsequent apnoeic episodes requiring bag-valve-mask ventilation before eventual recovery. Only protonitazene was detected in blood at a concentration of 0.74 µg/L. Case 2 was a young male who died shortly after being found unresponsive. The postmortem femoral blood concentrations of protonitazene and delta-9-tetrahydrocannabinol were 0.33 µg/L and 2 µg/L, respectively. Analysis of a pod vaping device found in the decedent's hand and a separate e-liquid bottle labelled as delta-9-tetrahydrocannabinol showed a mixture of protonitazene and delta-9-tetrahydrocannabinol. DISCUSSION: The opioid effects of protonitazene are mediated through ß-arrestin2 and mu opioid receptor signalling pathways. Benzimidazole opioids are lipophilic and, when mixed with a suitable solvent, can be used in a vape device. It is anticipated that naloxone would have provided effective reversal of toxicity in our cases. CONCLUSIONS: Novel routes of opioid administration, like vaping, may appear relatively innocuous in comparison to intravenous administration, but opioids may still be absorbed at high concentrations, resulting in severe opioid toxicity or death.

Revised nucleic acid test window periods: Applications and limitations in organ donation practice.

BACKGROUND: Nucleic acid test window periods for HIV, HCV, and HBV facilitate estimation of the residual risk of unexpected disease transmission and assist clinicians in determining the timeframe in which a recently acquired infection is at risk of nondetection. OBJECTIVES: Firstly, to provide revised estimates of the NAT window periods based on a currently used triplex NAT assay. Secondly, to examine their validity in organ donation and transplantation practice. METHOD: Estimates were based on the Procleix Ultrio Elite Assay (Grifols Diagnostic Solutions Inc. California, USA). The manufacturer's X50 and X95 limits of detection (LOD) were utilised. Viral doubling times of 0.85, 0.45, and 2.56 days and conversion factors for IU per ml to copies per mL of 0.6, 3.4, and 5 were assumed for HIV, HCV, and HBV respectively. Window periods were derived from the X50 and X95 LODs, based on a range of potential inoculum volumes. RESULTS: Calculated X50 window periods were 5.1 (4.5-5.8), 2.7 (2.4-2.9), and 16.6 (14.2-19.1) days for HIV, HCV, and HBV respectively. Calculated X50 window periods, based on whole body plasma volume, were 11.8 (10.3-13.3), 6.2 (5.6-6.8) and 36.7 (31.3-42.1) days respectively. CONCLUSION: X50 NAT window periods were significantly shorter for HBV and HCV and sit at the lower range of previously published estimates for HIV .  Current modeling assumptions may not account for all unexpected transmission events and may no longer be suitable for application to organ donation and transplantation.

Recently Acquired Blood-borne Virus Infections in Australian Deceased Organ Donors: Estimation of the Residual Risk of Unexpected Transmission.

Unexpected donor-derived infections of hepatitis B virus (HBV), hepatitis C virus (HCV), and HIV are rare but important potential complications of deceased organ transplantation. The prevalence of recently acquired (yield) infections has not been previously described in a national cohort of Australian deceased organ donors. Donor yield infections are of particularly significance, as they can be used to gain insights in the incidence of disease in the donor pool and in turn, estimate the risk of unexpected disease transmission to recipients. Methods: We conducted a retrospective review of all patients who commenced workup for donation in Australia between 2014 and 2020. Yield cases were defined by having both unreactive serological screening for current or previous infection and reactive nucleic acid testing screening on initial and repeat testing. Incidence was calculated using a yield window estimate and residual risk using the incidence/window period model. Results: The review identified only a single yield infection of HBV in 3724 persons who commenced donation workup. There were no yield cases of HIV or HCV. There were no yield infections in donors with increased viral risk behaviors. The prevalence of HBV, HCV, and HIV was 0.06% (0.01-0.22), 0.00% (0-0.11), and 0.00% (0-0.11), respectively. The residual risk of HBV was estimated to be 0.021% (0.001-0.119). Conclusions: The prevalence of recently acquired HBV, HCV, and HIV in Australians who commence workup for deceased donation is low. This novel application of yield-case-methodology has produced estimates of unexpected disease transmission which are modest, particularly when contrasted with local average waitlist mortality. Supplemental Visual Abstract; http://links.lww.com/TXD/A503.

Prevalence of Blood-Borne Viruses and Predictors of Risk in Potential Organ Donors in Australia.

Internationally, the designation of a patient as an increased viral risk organ donor has been associated with lower utilisation rates. The actual prevalence of blood borne viruses in Australian potential organ donors, and the predictive performance of questionnaires administered to stratify this risk, remains unknown. We conducted a retrospective review of all patients who commenced workup for donation on the national database between 2014-2020. The prevalence of HIV, Active HBV and Active HCV in 3650 potential organ donors was 0.16%, 0.9%, and 2.2%, respectively. The behavioural risk profile was assessed in a subset of 3633 patients. Next-of-kin reported increased risk behaviours were associated with an increased prevalence of HCV but not of HIV or HBV (OR 13.8, p < 0.01, OR 0.3. p = 0.42, OR 1.5, p = 0.14). Furthermore, the majority of HIV and HBV infections occurred in potential donors without a disclosed history of increased risk behaviours. In this series, donors had a higher prevalence of HCV, and similar rates of HBV and HIV to the broader community. Behavioural transmission risks were poorly predictive of HIV and HBV. Rather than pre-transplantation behavioural risk screening, routine post-transplant recipient screening may provide a more powerful tool in mitigating the consequences of unexpected viral transmission.

Remote COVID-19 patient monitoring system: a qualitative evaluation.

BACKGROUND: Many COVID-19 patients are discharged home from hospital with instructions to self-isolate. This reduces the burden on potentially overwhelmed hospitals. The Royal Melbourne Hospital (RMH) Home Monitoring Programme (HMP) is a model of care for COVID-19 patients which chiefly tracks pulse oximetry and body temperature readings. OBJECTIVE: To evaluate the feasibility and acceptability of the HMP from a patient perspective. DESIGN, SETTINGS AND PARTICIPANTS: Of 46 COVID-19 patients who used the HMP through RMH during April to August 2020, 16 were invited to participate in this qualitative evaluation study; all accepted, including 6 healthcare workers. Attempts were made to recruit a gender-balanced sample across a range of COVID-19 severities and comorbidities. Participants completed a brief semistructured phone interview discussing their experience of using the HMP. OUTCOME MEASURES AND ANALYSIS: A thematic analysis of interview data was conducted. Feasibility was defined as the HMP's reported ease of use. Acceptability was considered holistically by reviewing themes in the interview data. RESULTS: The HMP allowed clinical deterioration to be recognised as it occurred enabling prompt intervention. All participants reported a positive opinion of the HMP, stating it was highly acceptable and easy to use. Almost all participants said they found using it reassuring. Patients frequently mentioned the importance of the monitoring clinicians as an information conduit. The most suggested improvement was to monitor a broader set of symptoms. CONCLUSIONS: The HMP is highly feasible and acceptable to patients. This model of care could potentially be implemented on a mass-scale to reduce the burden of COVID-19 on hospitals. A key benefit of the HMP is the ability to reassure patients they will receive suitable intervention should they deteriorate while isolating outside of hospital settings.

The Rapid Development of Virtual Care Tools in Response to COVID-19: Case Studies in Three Australian Health Services.

BACKGROUND: News of the impact of COVID-19 around the world delivered a brief opportunity for Australian health services to plan new ways of delivering care to large numbers of people while maintaining staff safety through greater physical separation. The rapid pivot to telemedicine and virtual care provided immediate and longer term benefits; however, such rapid-cycle development also created risks. OBJECTIVE: The aim of this study was to understand the sociotechnical aspects of the rapid-cycle development of seven different COVID-19 virtual care tools, and to identify enablers, barriers, and risks at three health services in Victoria, Australia. METHODS: A qualitative, embedded, multiple case study design was adopted. Researchers from three health services collaborated with university researchers who were independent from those health services to gather and analyze structured interview data from key people involved in either clinical or technical aspects of designing and deploying seven different virtual care tools. RESULTS: The overall objectives of each health service reflected the international requirements for managing large numbers of patients safely but remotely and for protecting staff. However, the governance, digital maturity, and specific use cases at each institution shaped the methodology and specific outcomes required. Dependence on key individuals and their domain knowledge within an existing governance framework generally enabled rapid deployment, but sometimes posed barriers. Existing relationships with technical service developers enabled strong solutions, which in some cases were highly scalable. Conventional project methodologies such as steering committees, scope, budget control, tight functional specification, consumer engagement and codesign, universal accessibility, and postimplementation evaluation were ignored almost universally in this environment. CONCLUSIONS: These three health services took a variety of approaches to the rapid-cycle development of virtual care tools to meet their urgent needs for triaging and remote monitoring during the first year of the COVID-19 pandemic. Their experiences provided insights into many social and technical barriers and enablers to the development of virtual care tools. If these are addressed proactively, they will improve clinical governance and technical management of future virtual care. Some changes can be made within individual health services, while others entail health system policy reforms. Enhancing the environment for virtual care tool design and implementation now will yield returns not only during future health emergencies but also in many more routine care settings.

Threat of COVID-19 impacting on a quaternary healthcare service: a retrospective cohort study of administrative data.

OBJECTIVES: The threat of a pandemic, over and above the disease itself, may have significant and broad effects on a healthcare system. We aimed to describe the impact of the SARS-CoV-2 pandemic (during a relatively low transmission period) and associated societal restrictions on presentations, admissions and outpatient visits. DESIGN: We compared hospital activity in 2020 with the preceding 5 years, 2015-2019, using a retrospective cohort study design. SETTING: Quaternary hospital in Melbourne, Australia. PARTICIPANTS: Emergency department presentations, hospital admissions and outpatient visits from 1 January 2015 to 30 June 2020, n=896 934 episodes of care. INTERVENTION: In Australia, the initial peak COVID-19 phase was March-April. PRIMARY AND SECONDARY OUTCOME MEASURES: Separate linear regression models were fitted to estimate the impact of the pandemic on the number, type and severity of emergency presentations, hospital admissions and outpatient visits. RESULTS: During the peak COVID-19 phase (March and April 2020), there were marked reductions in emergency presentations (10 389 observed vs 14 678 expected; 29% reduction; p<0.05) and hospital admissions (5972 observed vs 8368 expected; 28% reduction; p<0.05). Stroke (114 observed vs 177 expected; 35% reduction; p<0.05) and trauma (1336 observed vs 1764 expected; 24% reduction; p<0.05) presentations decreased; acute myocardial infarctions were unchanged. There was an increase in the proportion of hospital admissions requiring intensive care (7.0% observed vs 6.0% expected; p<0.05) or resulting in death (2.2% observed vs 1.5% expected; p<0.05). Outpatient attendances remained similar (30 267 observed vs 31 980 expected; 5% reduction; not significant) but telephone/telehealth consultations increased from 2.5% to 45% (p<0.05) of total consultations. CONCLUSIONS: Although case numbers of COVID-19 were relatively low in Australia during the first 6 months of 2020, the impact on hospital activity was profound.

Characteristics, presentation and outcomes of music festival patrons with stimulant drug-induced serotonin toxicity.

OBJECTIVE: A large number of stimulant drug-associated deaths at music festivals in Australia were reported during the southern hemisphere summer of 2018-2019. This led to the prehospital deployment of healthcare professional-led critical care response teams. We aimed to describe the characteristics, clinical presentation, management and outcomes of music festival patrons with stimulant drug-induced serotonin toxicity managed using this model during the study period. METHODS: We performed a retrospective observational study of patients presenting with stimulant drug-induced serotonin toxicity and/or drug-induced hyperthermia who presented between December 2017 and December 2019. Comprehensive follow-up data were collected for those patients who required hospital admission. Data included demographics, clinical features, management and disposition, hospital outcomes and laboratory data, stratified by severity of presentation. RESULTS: Forty-seven patients were included. Median age was 21.9 years (interquartile range 19.6-22.2). 3,4-Methylenedioxymetamphetamine was the most frequently reported agent ingested (32/47). After stratification, 13 of 47 patients were classified as mild, 20 of 47 as moderate and 14 of 47 as severe. Median presenting temperature in this latter cohort was 41.1°C (40.5-42.0°C). All severely ill patients required intensive care unit admission, with a median hospital stay of 4.63 days (interquartile range 2.08-8.36). End-organ complications were reported in 11 of 14 patients. No mortalities were reported. All patients (13/13) from the mild cohort and 15 of 20 patients from the moderate cohort were treated and discharged on-site. CONCLUSIONS: Severe illness was associated with a high incidence of end-organ impairment. A high proportion of patients without severe disease were able to be successfully managed at the event without transport to hospital. No deaths are reported in this series.

Patients presenting for hospital-based screening for the coronavirus disease 2019: Risk of disease, and healthcare access preferences.

OBJECTIVE: Early during the coronavirus disease 2019 (COVID-19) pandemic, Australian EDs experienced an unprecedented surge in patients seeking screening. Understanding what proportion of these patients require testing and who can be safely screened in community-based models of care is critical for workforce and infrastructure planning across the healthcare system, as well as public messaging campaigns. METHODS: In this cross-sectional survey, we screened patients presenting to a COVID-19 screening clinic in a tertiary ED. We assessed the proportion of patients who met testing criteria; self-reported symptom severity; reasons why they came to the ED for screening and views on community-based care. RESULTS: We include findings from 1846 patients. Most patients (55.3%) did not meet contemporaneous criteria for testing and most (57.6%) had mild or no (13.4%) symptoms. The main reason for coming to the ED was being referred by a telephone health service (31.3%) and 136 (7.4%) said they tried to contact their general practitioner but could not get an appointment. Only 47 (2.6%) said they thought the disease was too specialised for their general practitioner to manage. CONCLUSIONS: While capacity building in acute care facilities is an important part of pandemic planning, it is also important that patients not needing hospital level of care can be assessed and treated elsewhere. We have identified a significant proportion of people at this early stage in the pandemic who have sought healthcare at hospital but who might have been assisted in the community had services been available and public health messaging structured to guide them there.

Distribution of potential eye and tissue donors within an Australian teaching hospital.

Eye and Tissue donation has the capacity to transform lives, yet the vast majority of potential in-hospital donors are not recognised. Studies which describe the relative importance of specific units or wards in determining the size of the donor pool are limited. The aim of this study was to map the distribution of potential Eye and Tissue donors within the study hospital. A 12-month retrospective analysis of all patient deaths at the study hospital was undertaken. The ability to donate corneal, heart valve, bone and skin tissue was investigated. Patients were classified as potential donors if they met specific age criteria and had an absence of contraindications based on electronic database search. There were 985 deaths during the study period. Deaths occurred under the care of 26 separate clinical units, and within 28 unique wards and treatment spaces. Four hundred and forty nine (45.6%) patients were identified as potential eye or tissue donors. The majority of potential donors occurred in ICU, Emergency and palliative care units. Of the subset of 328 deaths ≤ 70 years, the frequency of potential tissue donors was 55% (n = 181). ED and ICU had significantly higher frequencies of potential donor than other wards (86 and 77%, p < 0.01). The current study has identified the ED, ICU and PCUs are being important sites for potential Eye and Tissue Donors within our hospital. These will provide an important focus for future interventions to improve the rate of eye and tissue donation.

Estimation of the potential eye and tissue donor pool in an Australian emergency department.

OBJECTIVE: EDs have long been considered a potential source of eye and tissue donors, but no specific evidence to support this was identified in the Australian setting. The present study aims to bridge that knowledge gap, by analysing medical and social histories of those who have died over a 5 year period so as to determine donation eligibility in this population. METHODS: A retrospective audit was undertaken of all patients who died within the Royal Melbourne Hospital ED between 2010 and 2014. ED records, pharmacy records and electronic medical histories were audited for the presence of eye and tissue donation exclusion criteria and the distribution of these criteria within the target population. RESULTS: Over the 5 year period, of 326 deaths that occurred in the ED, one third was suitable for eye donation (n = 106) and one in seven (n = 45) for tissue donation. Of the age appropriate patients, five criteria were identified that excluded up to 85% of the population not eligible to donate. These were: haematological malignancies, neurodegenerative conditions, non-haematological malignancies, chronic renal failure and eye disease. CONCLUSION: The present study has identified a large pool of potential eye and tissue donors; a pool mostly unrecognised by emergency clinicians. An extensive list of exclusion criteria restricts donor potential. However, the present study has identified that only five fundamentally limit donation in the ED population. Utilisation of this knowledge will allow for the development of clinical triggers that will improve identification, and increase realisation, of potential donors.

Extreme sports: extreme physiology. Exercise-induced pulmonary oedema.

We report five patients who presented to an on-site medical team with concurrent haemoptysis and shortness of breath at a recent triathlon event. After initial management in the field, three of the five patients were transported to hospital via ambulance for further management, resulting in patients with haemoptysis and dyspnoea being 17 times more likely to require hospital transport. It is important to consider the differential diagnoses for this presentation, particularly exercise-induced pulmonary oedema.

Hospital in the field: prehospital management of GHB intoxication by medical assistance teams.

INTRODUCTION: Recreational use of gamma-hydroxybutyrate (GHB) is increasingly common at mass-gathering dance events in Australia. Overdose often occurs in clusters, and places a significant burden on the surrounding health care infrastructure. OBJECTIVE: To describe the clinical presentation, required interventions and disposition of patrons with GHB intoxication at dance events, when managed by dedicated medical assistance teams. METHODS: Retrospective analysis of all patrons attending St. John Ambulance medical assistance teams at dance events in the state of Victoria (Australia), from January 2010 through May 2011. Main outcome measures Clinical presentation, medical interventions and discharge destination. RESULTS: Sixty-one patients with GHB intoxication attended medical teams during the study period. The median age was 22 years, and 64% were male. Altered conscious state was present in 89% of attendances, and a GCS <9 in 44%. Hypotension, bradycardia and hypothermia were commonly encountered. Endotracheal intubation was required in three percent of patrons. Median length of stay onsite was 90 minutes. Ambulance transport to hospital was avoided in 65% of presentations. CONCLUSIONS: The deployment of medical teams at dance events and music festivals successfully managed the majority of GHB intoxications onsite and avoided acute care ambulance transfer and emergency department attendance.

Triage presenting complaint descriptions bias emergency department waiting times.

OBJECTIVES: The authors aimed to determine whether certain emergency department (ED) triage "presenting complaint" descriptions are associated with shorter or longer waiting times, when compared with matched controls. METHODS: This was a retrospective, analytical study in three tertiary referral EDs. Data relating to adult patients with Australasian National Triage Scale (NTS) Category 3-5 complaints, who presented over 1 year, were accessed. A pilot study of 25 emergency physicians (EPs) identified five most liked and five most disliked presenting complaints. For each liked or disliked complaint, "cases" were identified using key words and phrases in the triage presentation description. For each case, the previous presentation at that institution with the same NTS category was used as a "control." Cases and controls were compared for waiting time and proportions seen within the Australasian College for Emergency Medicine (ACEM)-recommended waiting times. RESULTS: Data on 28,566 case-control pairs were examined. Compared to their controls, three of the five most liked complaints (dislocations, fractures, and palpitations) had significantly shorter waiting times, and significantly more were seen within the recommended waiting times (p < 0.05). In contrast, three of the five most disliked complaints (dizziness, constipation, and back pain) had significantly longer waiting times, and significantly fewer were seen within the recommended waiting times (p < 0.05). Other presenting complaints showed similar, although nonsignificant, trends. CONCLUSIONS: Waiting times for patients with certain presenting complaints are significantly associated with triage presenting complaint descriptions. It is likely that these descriptions allow EPs to selectively seek or avoid patients with liked or disliked complaints, respectively. The impact of this for patients and ED flow needs investigation.

Mass gathering medicine: the Melbourne 2006 Commonwealth Games experience.

OBJECTIVE: To investigate the nature and acuity of medical presentations of patrons and staff attending the Melbourne 2006 Commonwealth Games (M2006) venues and festival live sites. DESIGN AND SETTING: Retrospective case series chart audit of patients who were managed by St John Ambulance during the M2006. PARTICIPANTS: Patients who presented requiring first-aid review or treatment at any of the 21 designated event venues or 16 live sites during their prescribed operating hours between 15 March 2006 and 26 March 2006. MAIN OUTCOME MEASURES: Provisional diagnosis and ambulance transport to hospital. RESULTS: A total of 3514 presentations occurred during the study period, of which 2279 (64.9%, 95% CI, 63.3%-66.4%) occurred at event venues. Headaches, soft tissue injuries, blisters and other wounds accounted for 64.1% (95% CI, 62.5%-65.73%) of presentations. A total of 303 patients were referred for further medical care, including 69 patients (1.96%, 95% CI, 1.54%-2.49%) who required transport to hospital via ambulance. Traumatic injuries accounted for 42.0% (95% CI, 30.5%-54.5%) of patients transported by ambulance to hospital. The patient presentation rate across all venues was 0.857 per 1000 patrons. The transport to hospital rate was 0.0186 per 1000 patrons. CONCLUSIONS: The majority of first-aid presentations during the M2006 were of low acuity and treatment resulted in return of patrons to the event, with only a small number requiring ambulance transport to hospital.

Nurofen Plus misuse: an emerging cause of perforated gastric ulcer.

Over a 6-month period, two patients presented to a community hospital emergency department with perforated gastric ulcers as the result of recreational misuse of over-the-counter ibuprofen-codeine preparations. Misuse of these medications appears to be an emerging cause of significant morbidity in patients with codeine addiction.