Induction of Labor at Term for Severe Antenatal Lead Poisoning.

INTRODUCTION: Antenatal lead exposure is associated with multiple adverse maternal and fetal consequences. Maternal blood lead concentrations as low as 10 µg/dL have been associated with gestational hypertension, spontaneous abortion, growth retardation, and impaired neurobehavioral development. Current treatment recommendations for pregnant women with a blood lead level (BLL) ≥ 45 µg/dL include chelation. We report a successful case of a mother with severe gestational lead poisoning treated with induction of labor in a term infant. CASE REPORT: A 22-year-old G2P1001 female, at 38 weeks and 5 days gestation, was referred to the emergency department for an outpatient venous BLL of 53 µg/dL. The decision was made to limit ongoing prenatal lead exposure by emergent induction as opposed to chelation. Maternal BLL just prior to induction increased to 70 µg/dL. A 3510 g infant was delivered with APGAR scores of 9 and 9 at 1 and 5 min. Cord BLL at delivery returned at 41 µg/dL. The mother was instructed to avoid breastfeeding until her BLLs decreased to below 40 µg/dL, consistent with federal and local guidelines. The neonate was empirically chelated with dimercaptosuccinic acid. On postpartum day 2, maternal BLL decreased to 36 µg/dL, and the neonatal BLL was found to be 33 µg/mL. Both the mother and neonate were discharged to an alternative lead-free household on postpartum day 4.

Intravenous Acetaminophen Overdose in an Infant With Toxicokinetic Data.

CASE REPORT: A 12-month-old (former 24 week gestational age), 8.7 kg male was hospitalized after an uneventful colostomy reversal. In the postoperative unit, the patient unintentionally received 1000 mg IV (114.9 mg/kg) acetaminophen instead of the intended 100 mg IV. Serial acetaminophen concentrations were drawn. The patient received IV Nacetylcysteine and ultimately had no adverse outcomes. DISCUSSION: This case report adds to the existing literature regarding toxicokinetics of IV APAP in infants. Our patient had a calculated ke of 0.263 h-1, correlating with a half-life of 2.63 hours. Based on current available data, the half-life of IV APAP in infants varies (2.6 to 4.9 hours). The reason for this variation is unknown and further research is needed in this area.

Breakthrough Seizure Associated With Kratom Use in Patients With Epilepsy.

PURPOSE OF REVIEW: Kratom (mitragynine) is a commercially available herbal supplement that is gaining popularity in the United States. Kratom is associated with a variety of neurologic effects. This review will discuss kratom's association with seizure through 3 cases and highlight what neurologists should know about kratom's clinical effects and legal status. RECENT FINDINGS: Kratom is currently commercially available, unscheduled by the US Drug Enforcement Administration, and a topic of regulatory debate in the United States. Large poison center reviews have suggested that kratom use is associated with seizure. There have been limited case studies to corroborate this finding. We present 3 cases in which seizures were associated with kratom use in patients treated for epilepsy. SUMMARY: Since 2008, kratom use is rising in prevalence in the United States aided by lack of regulation. Neurologists need to be aware of its association with seizure and other neurologic side effects.

Automated Indentation Demonstrates Structural Stiffness of Femoral Articular Cartilage and Temporomandibular Joint Mandibular Condylar Cartilage Is Altered in FgF2KO Mice.

OBJECTIVE: Employ an automated indentation technique, using a commercially available machine, to assess the effect of fibroblast growth factor 2 (FGF2) expression on structural stiffness over the surface of both murine femoral articular cartilage (AC) and temporomandibular joint (TMJ) mandibular condylar cartilage (MCC). DESIGN: Experiments were performed using 3-month-old female homozygote Fgf2KO mice with wild type (WT) littermates. After euthanization, isolated mandibles and hindlimbs were either processed for histology or subjected to automated indentation on a Biomomentum Mach-1 v500csst with a 3-axis motion controller in a phosphate buffered saline bath using a 0.3 mm spherical tip indenter. The effect of indentation depth on normal force was characterized, then structural stiffness was calculated and mapped at multiple positions on the AC and MCC. RESULTS: Automated indentation of the AC and TMJ MCC was successfully completed and was able to demonstrate both regional variation in structural stiffness and differences between WT and Fgf2KO mice. Structural stiffness values for Fgf2KO AC were significantly smaller than WT at both the medial/anterior (P < 0.05) and medial/posterior (P < 0.05) positions. Global Fgf2KO also lead to a decrease in MCC thickness of the TMJ compared with WT (P < 0.05) and increased structural stiffness values for Fgf2KO at both the posterior and anterior location (P < 0.05). CONCLUSIONS: Automated indentation spatially resolved differences in structural stiffness between WT and Fgf2KO tissue, demonstrating FGF2 expression affects femoral AC and TMJ MCC. This quantitative method will provide a valuable approach for functional characterization of cartilage tissues in murine models relevant to knee joint and TMJ health and disease.

Prepacked naloxone administration for suspected opioid overdose in the era of illicitly manufactured fentanyl: a retrospective study of regional poison center data.

Background: Prepacked naloxone kits (PNKs) are frequently used to reverse opioid intoxication. It is unknown if the presence of illicitly manufactured fentanyl and its analogs (IMFs) in heroin supply is affecting the PNK doses given by laypersons. We investigated the trend of PNK dose administered to reverse opioid toxicity in suspected/undifferentiated opioid intoxication.Methods: We retrospectively reviewed PNK administrations reported to the Maryland Poison Center between 1 January 2015 and 15 October 2017. Primary outcome was the mean PNK dose administered to reverse opioid-induced central nervous system and ventilatory depression. Secondary outcomes included the reversal rate of opioid toxicity, patient disposition, and survival rate.Results: Our analysis involved 1139 PNK administrations. The mean age of subjects was 34.3 years; 68.8% (n = 781) were male. Ventilatory depression was present in 98.2% (n = 958) of cases, and 97% (n = 1097) were unresponsive. Law enforcement administered the majority of PNK (91.0%; n = 1035); the primary route was intranasal (97.9%; n = 1051). Toxicity was reversed in 79.2% (n = 886) of overdose victims after a mean PNK dose of 3.12 mg. EMS personnel gave 291 subjects additional naloxone (mean: 2.2 mg), reversing opioid toxicity in 94.2% (n = 254). Between 2015 and 2017, the mean PNK dose increased from 2.12 to 3.63 mg (p < .0001) while the reversal rate decreased from 82.1% to 76.4% (p = .04). One hundred and eighty-two patients (15.9%) refused transport; of those transported to a hospital, 73.4% (n = 569) were treated and released and 12.4% (n = 96) required hospitalization. Ninety-six percent (n = 1092) of the subjects survived. Forty subjects were pronounced dead at the scene. Fentanyl or its analog was detected in 36 of 55 opioid-related deaths (65.5%).Conclusions: PNK administration reversed toxicity in the majority of patients with undifferentiated opioid intoxication. Between 2015 and 2017, increasing doses of PNK were administered but the reversal rate decreased. These trends are likely multifactorial, including increasing availability of IMFs.

Female Nonobstetric Genitourinary Emergencies.

The emergency medicine provider sees a broad range of pathology involving the female genitourinary system on a daily basis. Must-not-miss diagnoses include pelvic inflammatory disease and ovarian torsion, because these diagnoses can have severe complications and affect future fertility. Although most patients with abnormal uterine bleeding are hemodynamically stable, it can present as a life-threatening emergency and providers should be adept managing severe hemorrhage. Bartholin gland cysts are common complaints that often require procedural intervention. This article discusses these diagnoses and appropriate evaluation and management in the emergency department.