Responding to the Opioid Epidemic: Educational Competencies for Pain and Substance Use Disorder from the Medical Schools of the University of California.

OBJECTIVE: The University of California (UC) leadership sought to develop a robust educational response to the epidemic of opioid-related deaths. Because the contributors to this current crisis are multifactorial, a comprehensive response requires educating future physicians about safe and effective management of pain, safer opioid prescribing, and identification and treatment of substance use disorder (SUD). METHODS: The six UC medical schools appointed an opioid crisis workgroup to develop educational strategies and a coordinated response to the opioid epidemic. The workgroup had diverse specialty and disciplinary representation. This workgroup focused on developing a foundational set of educational competencies for adoption across all UC medical schools that address pain, SUD, and public health concerns related to the opioid crisis. RESULTS: The UC pain and SUD competencies were either newly created or adapted from existing competencies that addressed pain, SUD, and opioid and other prescription drug misuse. The final competencies covered three domains: pain, SUD, and public health issues related to the opioid crisis. CONCLUSIONS: The authors present a novel set of educational competencies as a response to the opioid crisis. These competencies emphasize the subject areas that are fundamental to the opioid crisis: pain management, the safe use of opioids, and understanding and treating SUD.

A Multiple-Mini Interview (MMI) for Emergency Medicine Residency Admissions: A Brief Report and Qualitative Analysis.

INTRODUCTION: A multiple-mini interview (MMI) is a type of structured interview, which may assess many non-cognitive domains in residency applicants. There are few studies on MMI during the emergency medicine (EM) residency admissions process in the United States. We sought to determine the strengths, weaknesses, and acceptability of a pilot MMI for EM residency admissions. METHODS: We piloted a five-station MMI with nine residency applicants. Following the MMI, we surveyed all participants, using 15 open- and closed-ended questions. Using grounded theory analysis, we coded the responses to the post-intervention survey to uncover the strengths and weaknesses of the MMI for EM residency admissions. RESULTS: All nine students completed the survey. A positive theme that emerged from the survey was that the MMI was a positive, unexpected experience (all respondents, n=9). Candidates felt they were able to showcase unique talents, which would not be observed during a traditional interview (n=3). A negative theme that emerged from the survey was that the experience was intimidating (n=3). Candidates felt that the MMI left out important aspects of a typical interview day (n=3); such as, time for the candidate to become more familiar with the program. CONCLUSIONS: An MMI may be a positive experience for candidates, but may also induce more anxiety. The MMI may omit an important piece of the interview day: an opportunity for the applicants to familiarize themselves with the residency program.

Reversible Acute Kidney Injury Associated with Chlorothalonil Ingestion.

A 43-year-old man ingested a chlorothalonil-containing fungicide in a suicide attempt. The patient was found to have acute kidney injury from acute tubular necrosis on hospital admission (serum creatinine 2.9 mg/dL), although his renal function recovered with hydration and supportive care. Acute toxicity from chlorothalonil ingestion has been described very rarely, and no previous cases have described clinically-significant renal effects.

Recurrent coagulopathy with delayed significant bleeding after crotaline envenomation.

OBJECTIVES: Report of delayed significant coagulopathy, thrombocytopenia, and bleeding after Crotaline envenomation. METHODS: Recurrent coagulopathy and thrombocytopenia have been described after treatment of Crotaline envenomation with Crotalidae polyvalent immune Fab (CroFab). Until now, there have been no reports of significant spontaneous bleeding despite these abnormalities. RESULTS: Crotalidae polyvalent immune Fab has a relatively short half-life compared with previous antivenoms used to treat snake bite. This shorter half-life allows for recurrence of venom effects. Therefore, patients with Crotaline envenomation should undergo close monitoring for recurrence of coagulopathy or thrombocytopenia after treatment with CroFab. CONCLUSIONS: If coagulopathy or thrombocytopenia recurs, retreatment with CroFab should be considered to prevent significant bleeding.

Ultrastructural changes in rat thyroid tissue after acute organophosphate poisoning and effects of antidotal therapy with atropine and pralidoxime: A single-blind, ex vivo study.

BACKGROUND: Organophosphate (OP) insecticides are widely used in both agricultural and landscape pest control, and the potential for human exposure to these compounds is significant. OBJECTIVES: The aims of this study were to investigate the effects of acute poisoning with the OP methamidophos and the effects of antidotal therapy with atropine and pralidoxime on rat thyroid tissue ultrastructure. METHODS: In this single-blind, ex vivo study, male Wistar albino rats weighing 220 to 230 g were divided into 4 treatment groups. Group 1 received a median lethal dose of methamidophos (30 mg/kg) via oral gavage. Group 2 received saline via oral gavage and served as the control group for group 1. Group 3 received methamidophos (30 mg/kg) via oral gavage, and after 8 minutes atropine 0.05 mg/kg and pralidoxime chloride (2-FAM) (40 mg/kg) were administered intraperitoneally (IP). Atropine was titrated to reverse signs of cholinergic excess. Group 4 received saline via oral gavage followed by IP injections and served as the control for group 3. Rat thyroid tissues were examined using electron microscopy, and the histologic changes were examined by a histopathologist who was blinded to treatment. All rats were euthanized by intracardiac blood collection. The rats in groups 1 and 2 were euthanized 8 minutes after treatment. The rats in groups 3 and 4 were euthanized 96 hours after treatment. RESULTS: Thirty-four male rats (aged 16 weeks) were included in the study. The rats were grouped accordingly: group 1 (n = 10); group 2 (n = 7); group 3 (n = 10); and group 4 (n = 7). The mean (SD) pseudocholinesterase (FCE) activity was significantly lower in the methamidophos-treated rats (group 1) compared with the corresponding control group (group 2) (32.6 [17.0] vs 579.4 [59.0] U/L, respectively; P < 0.001). PCE activity was significantly higher in rats treated with atropine and 2-PAM (group 3) (392.5 [39.4] U/L; P < 0.001) compared with those not receiving antidotal therapy (group 1). Group 1 experienced changes in thyrocytes and organelles that were not detected in the antidote-treated rats in group 3. These changes included follicular cell nuclei exhibiting an increase in chromatin content, pyknotic nuclei, mitochondrial degeneration, dilated granular endoplasmic reticulum cisternae, reduced microvilli, and intraluminal cellular debris. Within follicular cells, formation of vacuoles filled with fine granular material was noted. CONCLUSION: Acute OP poisoning was associated with histopathologic effects in rat thyroid tissue that appeared to be mitigated by antidotal therapy in this small animal study. More extensive studies using immunohistochemical methods are needed.

Fluoxetine overdose-induced seizure.

A 37-year-old woman experienced a witnessed generalized seizure in the Emergency Department three hours after ingesting approximately 1400 mg of fluoxetine in a suicide attempt. Although the majority of fluoxetine ingestions are benign, seizures may occur after large intentional overdoses.

Fatal metformin overdose presenting with progressive hyperglycemia.

A 29-year-old man with no history of diabetes ingested over 60 grams of metformin in a suicide attempt. He presented to the emergency department with acute renal insufficiency, severe lactic acidosis, and rapidly-progressive hyperglycemia. The patient's peak serum glucose level of 707 mg/dL is the highest yet reported in a case of metformin toxicity. Treatment included sodium bicarbonate infusion and hemodialysis, but the patient suffered several cardiac arrests with pulseless electrical activity and ultimately expired 25 hours after the ingestion.

Ultrastructural effects of acute organophosphate poisoning on rat kidney.

We investigated the ultrastructural effects of the organophosphate compound methamidophos and treatment with atropine and pralidoxime (2-PAM) on rat kidneys. Male Wistar albino rats were assigned to four groups. Group 1 received 30 mg/kg methamidophos, the LD50 for this compound in rats, via oral gavage. Group 2 received only physiologic saline. Group 3 rats received 30 mg/kg methamidophos and were treated with 2-PAM and atropine via intraperitoneal injection when cholinergic symptoms were noted. Group 4 served as a control, and received physiologic saline in equivalent volumes and routes to Group 3. Kidney tissues were prepared for electron microscopic studies. No ultrastructural changes were detected in Group 1 after acute poisoning with methamidophos and in Group 3 treated with antidotes after poisoning. Acute organophosphate poisoning and antidotal treatment in this model are not associated with histopathological changes in the rat kidney but the models with different organophosphate compounds, by administrating the different dosages, may be more illuminative in explaining the effects of these chemicals in kidney.

Physician knowledge of herbal toxicities and adverse herb-drug interactions.

OBJECTIVE: To determine how knowledgeable physicians are regarding the toxic effects and drug interactions of herbal remedies. METHODS: An anonymous voluntary demographic survey and 16-question, multiple-choice quiz was distributed at educational meetings of emergency medicine and internal medicine physicians. The primary outcome measures were to determine whether significant associations existed between quiz scores and the amount of clinical experience, or between quiz scores and self-assessed familiarity with the topic of herbal toxicities and adverse herb-drug interactions. RESULTS: A total of 142 surveys and quizzes were completed by 59 attending physicians, 57 resident physicians, and 26 medical students. The mean subject score on the quiz was only slightly higher than would have occurred from random guessing. Neither the amount of the subjects' clinical experience, nor their self-assessed familiarity with herbal toxicities and drug interactions correlated significantly with the score on the quiz. CONCLUSION: The physicians and medical students surveyed had little training in herbal toxicities and drug interactions. They generally rated their familiarity with these topics as 'poor', and their scores on the quiz bore out this assessment as correct. Educational efforts might improve physician knowledge of the adverse effects of herbal remedies.

Assessing physostigmine's contraindication in cyclic antidepressant ingestions.

Ingestion of cyclic antidepressant medications or prolongation of the electrocardiographic QRS interval are commonly considered as contraindications to the use of physostigmine as an antidote for antimuscarinic toxicity. This dictum seems to stem from a few well-publicized cases in which administration of physostigmine was temporally associated with the development of asystole. Before the report of these cases, physostigmine was more frequently used and had been considered a first-line antidote for both the neurologic and cardiac toxic effects of cyclic antidepressant overdose. This apparent inconsistency, and a resurgence of interest in physostigmine as an antidote, begs the question of the appropriateness of this drug's contraindication in all cyclic antidepressant ingestions. Review of the published clinical and experimental evidence provides little support for the clinical utility of using electrocardiographic criteria or the ingestion of cyclic antidepressants as contraindications to the use of physostigmine.

I Can't Believe It's Not Toothpaste! Poison Control Center Calls Regarding Dental and Oral-Care Products.

BACKGROUND: A cluster of incidents in which non-tooth-paste products were used to brush teeth prompted a review of all calls to one Poison Control Center (PCC) regarding exposures to dental and oral-care products to determine if any resulted in significant toxicity. METHODS: Retrospective review of 65,849 calls to one PCC during one calendar year. All inquiries about exposures to substances used as dental or oral-care products were analyzed by a single reviewer for reported adverse effects; including hospital admission or PCC referral for emergent medical evaluation. RESULTS: 798 calls involved exposure to dental or oral-care products, comprising 1.21 % of all calls received. Toothbrushing incidents with non-toothpaste products (122 cases) did not result in any significant recognized toxicity. Twenty-four patients were either referred for emergent medical evaluation (14) or were admitted to the hospital (10). In 23 of these patients (96%), the toxic agent was either an over-the-counter analgesic or a local anesthetic used to treat dental pain. CONCLUSIONS: Among PCC calls received regarding dental and oral-care products, over-the-counter analgesics and local anesthetics used for dental pain resulted in the most frequent need for emergent medical evaluation or for hospital admission.