Loperamide-Induced Torsades de Pointes: A Case Series.

BACKGROUND: Loperamide is an over-the-counter, inexpensive, antidiarrheal opioid that can produce life-threatening toxicity at high concentrations. CASE REPORT 1: A 28-year-old man with a history of depression and substance abuse disorder (SUD) presented to the emergency department (ED) with shortness of breath and lightheadedness. He ingested large amounts of loperamide daily. The patient's initial electrocardiogram (ECG) demonstrated sinus rhythm, right axis deviation, undetectable PR interval, QRS 168 ms, and QTc 693 ms. He was administered intravenous sodium bicarbonate and magnesium sulfate and admitted to the intensive care unit, eventually developing Torsades de Pointes (TdP). He was given lidocaine and isoproterenol infusions, and an external pacemaker was placed. He was discharged in stable condition on hospital day (HD) 16. CASE REPORT 2: A 39-year-old woman with a history of hepatitis C, depression, and SUD was transported to the ED after reported seizure-like activity. The patient experienced TdP in the ED and admitted to ingesting large amount of loperamide daily. An ECG demonstrated sinus rhythm, right axis deviation, PR interval 208 ms, QRS interval 142 ms, and QTc 687 ms. She was administered intravenous magnesium, sodium bicarbonate, and isoproterenol. After intensive care unit admission, the patient experienced no further TdP and was discharged on HD 6. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians should proceed with caution when treating patients with loperamide toxicity. Even in asymptomatic patients and drug discontinuance, obtain consultation with a medical toxicologist, promptly treat ECG abnormalities aggressively, and admit all patients for further monitoring.

The pharmacist's role in overdose: Using mapping technologies to analyze naloxone and pharmacy distribution.

OBJECTIVES: To present preliminary research using geographic information system (GIS) mapping as a tool that can be integrated into pharmacy practice to increase access to and utilization of pharmacy-based interventions, including the distribution of naloxone. METHODS: Overdose death data was collected from medical examiner reports in an online database, and pharmacies carrying and distributing naloxone were determined by ZIP Code Tabulation Areas (ZCTAs) in Allegheny County, PA. The distribution of overdose death rates was analyzed in relation to naloxone-carrying pharmacies and all licensed pharmacies in the county with the use of GIS mapping. RESULTS: Eighty-seven ZCTAs were included. Of 322 active licensed pharmacies, 28 pharmacies were confirmed to carry and distribute naloxone. The number of overdose deaths in ZCTAs that have naloxone-distributing pharmacies was significantly higher than the average number of deaths in all ZCTAs in Allegheny County: 7.38 deaths versus 4.84 deaths, respectively (P = 0.021). CONCLUSION: This report illustrates the value of GIS mapping in monitoring the impact of overdose death prevention efforts, including the availability of naloxone in pharmacies. Analysis of these data over the next 5 years will provide valuable information on the potential impact of naloxone-distributing pharmacies on overdose rates, which, in turn, will inform pharmacists and pharmacy organizations on the value of carrying naloxone in pharmacies and inform local communities of its availability.

Patterns and trends in accidental poisoning death rates in the US, 1979-2014.

OBJECTIVES: The purpose of this study was to examine US accidental poisoning death rates by demographic and geographic factors from 1979 to 2014, including High Intensity Drug Trafficking Areas. METHODS: Crude and age-adjusted death rates were formed for age group, race, sex, and county for accidental poisonings (ICD 9th revision: E850-E869; ICD 10th revision: X40-X49) from 1979 to 2014 using the Mortality and Population Data System housed at the University of Pittsburgh. Rate ratios were calculated comparing rates from 2014 to 1979, overall, by sex, age group, race, and county. Joinpoint regression detected changes in trends and calculated the average annual percentage change (AAPC) as a summary measure of trend. RESULTS: Drug poisoning mortality rates have risen an average of 6% per year since 1979. Increases are occurring in all ages 15+, and in all race-sex groups. HIDTA counties with the highest mortality rates were in Appalachia and New Mexico. Many of the HIDTA border counties had lower rates of mortality. CONCLUSIONS: The drug poisoning mortality epidemic is continuing to grow. While HIDTA resources are appropriately targeted at many areas in the US most affected, rates are also rapidly rising in some non-HIDTA areas.

The psychosocial experience of individuals living with osteogenesis imperfecta: a mixed-methods systematic review.

PURPOSE: Osteogenesis imperfecta (OI) is a genetic disorder (prevalence: 1:10,000), leading to bone fragility, frequent fractures, and varying degrees of physical limitations. Despite a substantial amount of research on the genetics, pathophysiology, and treatments related to OI, there remains a paucity of knowledge concerning the lived psychosocial experience of the OI population. This mixed-methods systematic review aimed to review, appraise, and synthesize the literature on the psychosocial experience of children and adults with OI with the goal of identifying implications for research, practice, and policy-making. METHODS: Using a systematic methodology, quantitative, qualitative, and mixed-methods studies were accessed through database searching, screened, assessed for eligibility, and appraised. Data from the selected studies fulfilling the eligibility and quality criteria were extracted and synthesized using thematic analysis with an inductive approach. RESULTS: A total of four qualitative and 20 quantitative studies, with various study designs and methodologies ranging in quality, were included in the review (n = 800; comprising 610 children and 175 adults with OI types I, III, IV, and V, ten parents and five healthcare professionals). Six themes were identified: intellectual feats, isolation and feeling different, fear of fractures, coping with challenges, adapting by learning new skills, and social relationships. CONCLUSION: These findings highlighted key aspects of the experiences of children and adults with OI and will be essential for improving the quality and direction of research, tailoring clinical interventions addressing the psychosocial needs and quality of life of individuals with OI, and raising awareness among caregivers, healthcare professionals, administrators, and policy-makers associated with the OI population.

Coxsackievirus B4 myocarditis and meningoencephalitis in newborn twins.

Coxsackievirus B4 (CB4) is a picornavirus associated with a variety of human diseases, including neonatal meningoencephalitis, myocarditis and type 1 diabetes. We report the pathological findings in twin newborns who died during an acute infection. The twins were born 1 month premature but were well and neurologically intact at birth. After a week they developed acute lethal neonatal sepsis and seizures. Histopathology demonstrated meningoencephalitis and severe myocarditis, as well as pancreatitis, adrenal medullitis and nephritis. Abundant CB4 sequences were identified in nucleic acid extracted from the brain and heart. In situ hybridization with probes to CB4 demonstrated infection of neurons, myocardiocytes, endocrine pancreas and adrenal medulla. The distribution of infected cells and immune response is consistent with reported clinical symptomatology where systemic and neurological diseases are the result of CB4 infection of select target cells.

Estimating metabolic rate from International Organization for Standardization heart rate method and two walking equations.

Assigning a value for metabolic rate is central to heat stress assessment. ISO 8996 describes a predictive method for walking based on the American College of Sports Medicine (ACSM) method and another generalized method based on average heart rate. In addition, the US Army uses the load carriage decision aid (LCDA) predictive equation to estimate metabolic rate. The purpose of this study was to assess the accuracy/bias and precision of the ISO heart rate method and the ACSM and LCDA equations. The laboratory database included metabolic rate, heart rate, treadmill speed, and grade during a progressive heat stress protocol. Treadmill speed and grade were set to represent one of three metabolic rates. Accuracy and precision were assessed with Bland-Altman plots. All three methods had good accuracy (low bias). For precision, the ISO heart rate method had a root mean square error (RMSE) of 34 W and 11% when adjusted for repeated measures. The RMSE for two equations was 20 W and 7%. Although the heart method had less accuracy, its application is more generalizable. The heart rate method should be used below the occupational exposure limit to avoid a bias toward higher predicted values due to heat strain.

Analysis of the community behavioural patterns in management of household plastic waste due to the COVID-19 pandemic in Sri Lanka.

The COVID-19 pandemic has adversely affected human lifestyle in numerous ways and one such key affected social element is the management of household plastic waste. Due to its effective barrier properties against the COVID-19 virus, usage and consumption of personal protective equipment (PPE) and other single-use plastic (SUP) products have increased exponentially to meet the accelerated demand. Therefore, this paper analyses the changes in community behavioural patterns of household plastic waste management with the prevailing COVID-19 pandemic situation in Sri Lanka. The comparative analysis of majorly consumed plastic waste types, plastic disposal methods, and perceptions of existing policies before and after the pandemic are broadly discussed. A comprehensive questionnaire was conducted in a stratified randomly sampled community and analysed using SPSS. Disposable face masks (39.9%) and hand sanitiser products (33.0%) were popular plastic products during the pandemic. The frequency of handing over the waste to collectors and recycling centres decreased slightly, from 32.1% to 31.4% and 24.2%-19.8%, respectively. Conversely, respondents' preference for burning plastic waste increased from 23.4% to 27.0% after the pandemic. The plastic disposal methods from before and after the pandemic are significantly associated with income level (p = 0.00) and employment status (p = 0.00). No significant association was observed between the disposal method before the pandemic and the education level of respondents (p = 0.185). However, a significant association was evident between the disposal method after the pandemic and the education level of respondents (p = 0.025).

Accidental through and through penetrating injury to the neck.

We present the case of a 24-year-old driver who died when a metal pole entered the front windshield, traveled through the victim's neck, and then exited via the back windshield. This case illustrated an unusual penetration injury and the importance of a thorough and complete death scene investigation.

Unsuspected hereditary hemochromatosis at forensic autopsy: its presentation, confirmation, and implications.

Hereditary hemochromatosis (HH) is one of the most common genetic disorders and may present clinically in a variety of ways. The most common presentation is micronodular cirrhosis with possible associated diabetes. However, HH may also present with cardiac dysfunction and sudden death. The confirmation of unsuspected HH at autopsy is complicated by the growing number of genetic abnormalities, which are not detected by current commercial genetic testing for C282Y and H63D mutations. Consequently, quantitative liver iron studies on fresh or paraffin embedded liver is recommended in confirming HH. The importance of detection and confirmation of HH cannot be overemphasized given the need to screen surviving family members in preventing organ damage of asymptomatic individuals. We present a case of a 38-year-old white woman with micronodular cirrhosis secondary to unsuspected HH that was confirmed by a quantitative liver iron study. The possible presentation of cardiac sudden death from HH, confirmation issues and implications of a HH diagnosis for surviving family members are also discussed.

Meeting EU ELV targets: Pilot-scale pyrolysis automotive shredder residue investigation of PAHs, PCBs and environmental contaminants in the solid residue products.

The EU's publication of the 2017 End-of-Life Vehicle Recycling and Recovery results reported that the UK failed to meet its targets. The Commission's data showed that the UK only achieved a rate of 94.1% falling short of the 95% target. The treatment of automotive shredder residue (ASR) using pyrolysis technologies offers a potential solution to this shortfall. The pyrolysis products could contribute to the target as well as supporting the circular economy package. However, there are questions about their hazardous nature and whether they qualify as secondary products. ASR, from a commercial plant, was processed through a pilot-scale pyrolysis unit, which separated the char into two fractions: coarse ≥0.1 mm and fine ≤0.1 mm. These were chosen as potential commercial products. Chars were produced from two processing temperatures of 800 and 1000 °C. These temperatures maximise gas production and produce the best "quality" char in terms of limiting organic contamination. It was found that the toxicity of the chars changed with both processing temperature and size fraction; with the maximum total PAHs concentration in the fine fraction at 800 °C. The coarse fractions were shown to be non-hazardous. It is suggested that some form of post-separation may be required to remove the hazardous component. The implication was that non-separated char could be classified as hazardous even if its overall characteristics were not, due to the role of dilution. If there were any questions about the status of the char this could prevent the use of ASR to meet the higher ELV target.

Challenges around automotive shredder residue production and disposal.

The challenge for the automotive industry is how to ensure they adopt the circular economy when it comes to the disposal of end-of-life vehicles (ELV). According to the European Commission the UK achieved a total reuse and recovery rate of 88%. This is short of the revised ELV directive target of 95% materials recovery, which requires a minimum of 85% of materials to be recycled or reused. A significant component of the recycling process is the production of automotive shredder residue (ASR). This is currently landfilled across Europe. The additional 10% could be met by processing ASR through either waste-to-energy facilities or Post shredder technology (PST) to recover materials. The UK auto and recycling sectors claimed there would need to be a massive investment by their members in both new capacity and new technology for PST to recover additional recycle materials. It has been shown that 50% of the ASR contains valuable recoverable materials which could be used to meet the Directive target. It is expected in the next 5years that technological innovation in car design will change the composition from easily recoverable metal to difficult polymers. This change in composition will impact on the current drive to integrate the European Circular Economy Package. A positive factor is that main driver for using ASR is coming from the metals recycling industry itself. They are looking to develop the infrastructure for energy generation from ASR and subsequent material recovery. This is driven by the economics of the process rather than meeting the Directive targets. The study undertaken has identified potential pathways and barriers for commercial thermal treatment of ASR. The results of ASR characterisation were used to assess commercial plants from around the world. Whilst there were many claiming that processing of ASR was possible none have so far shown both the technological capability and economic justification.

The Effect of Incomplete Death Certificates on Estimates of Unintentional Opioid-Related Overdose Deaths in the United States, 1999-2015.

OBJECTIVES: A complete and accurate count of the number of opioid-related overdose deaths is essential to properly allocate resources. We determined the rate of unintentional overdose deaths (non-opioid-related, opioid-related, or unspecified) in the United States and by state from 1999 to 2015 and the possible effects of underreporting on national estimates of opioid abuse. METHODS: We abstracted unintentional drug overdose deaths ( International Classification of Diseases, 10th Revision, codes X40-X44) with contributory drug-specific T codes (T36.0-T50.9) from the Mortality Multiple Cause Micro-Data Files. We assumed that the proportion of unspecified overdose deaths that might be attributed to opioids would be the same as the proportion of opioid-related overdose deaths among all overdose deaths and calculated the number of deaths that could be reallocated as opioid-related for each state and year. We then added these reallocated deaths to the reported deaths to determine their potential effect on total opioid-related deaths. RESULTS: From 1999 to 2015, a total of 438 607 people died from unintentional drug overdoses. Opioid-related overdose deaths rose 401% (from 5868 to 29 383), non-opioid-related overdose deaths rose 150% (from 3005 to 7505), and unspecified overdose deaths rose 220% (from 2255 to 29 383). In 5 states (Alabama, Indiana, Louisiana, Mississippi, and Pennsylvania), more than 35% of unintentional overdose deaths were coded as unspecified. Our reallocation resulted in classifying more than 70 000 unspecified overdose deaths as potential additional opioid-related overdose deaths. CONCLUSIONS: States may be greatly underestimating the effect of opioid-related overdose deaths because of incomplete cause-of-death reporting, indicating that the current opioid overdose epidemic may be worse than it appears.

Report of Increasing Overdose Deaths that include Acetyl Fentanyl in Multiple Counties of the Southwestern Region of the Commonwealth of Pennsylvania in 2015-2016.

Acetyl fentanyl is a Schedule I controlled synthetic opioid that is becoming an increasingly detected "designer drug." Routine drug screening procedures in local forensic toxicology laboratories identified a total of 41 overdose deaths associated with acetyl fentanyl within multiple counties of the southwestern region of the state of Pennsylvania. The range, median, mean, and standard deviation of blood acetyl fentanyl concentrations for these 41 cases were 0.13-2100 ng/mL, 11 ng/mL, 169.3 ng/mL, and 405.3 ng/mL, respectively. Thirty-six individuals (88%) had a confirmed history of substance abuse, and all but one case (96%) were ruled multiple drug toxicities. This report characterizes this localized trend of overdose deaths associated with acetyl fentanyl and provides further evidence supporting an alarmingly concentrated opiate and opioid epidemic of both traditional and novel drugs within this region of the United States.

The Rapid Escalation of Fentanyl in Illicit Drug Evidence in Allegheny County, Pennsylvania, 2010-2016.

Opioid overdose deaths in the United States quadrupled from 1999 (n = 8050 deaths) to 2015 (n = 33 091 deaths), and the number of deaths associated with synthetic opioids, such as fentanyl, increased from 3105 deaths in 2013 to nearly 20 000 deaths in 2016. Given this rapid increase, timely surveillance for drugs in circulation is crucial. However, current surveillance systems used to track drug overdoses do not detect new drugs in circulation quickly. We studied the change in the presence of fentanyl in "stamp bag" drug evidence in Allegheny County, Pennsylvania, from 2010 through 2016. Stamp bags are small wax packets with individual stamps that contain mixtures of drugs, most commonly heroin, that law enforcement officers seize and retain as legal evidence. The proportion of stamp bags determined to contain fentanyl or a fentanyl analog was 2.1% in 2014 and rose sharply to 17.1% in 2016. Monitoring the chemical makeup of drug evidence items could help public health authorities identify drug use trends in their jurisdictions.

Drug Overdose Surveillance and Information Sharing via a Public Database: The Role of the Medical Examiner/Coroner.

The medical examiner/coroner (ME/C) death scene investigation systems of the United States play a pivotal role in the current public health crisis created by the expanding drug dependency epidemic in the United States. The first point of recognition of a drug-related death in a community is often the local ME/C agency. This circumstance places these entities in an ideal position to provide surveillance data regarding the epidemiology of drug-related deaths occurring within the jurisdiction of the agency. The ability to surveil for the distribution and determinants among drug-related deaths at the first point of contact enhances the capacity to recognize actionable trends at the local, state, and national levels, including the ability to identify secular (longer-term) trends among various drugs and population subgroups, as well as activity spikes (outbreaks) associated with high-potency formulations and drug combinations. In this article, we describe the development and implementation of an online website that provides public access to a wide array of drug-related death surveillance resources and tools. The website gives users access to a detailed dataset that includes information regarding specific drugs, demographic information pertaining to the decedent, and to investigational findings related to the circumstances of the death. A unique aspect of the database is that it is populated by ME/C agencies and accessed by the public with no intermediary agency, so that the lag time between the identification and investigation of the death as drug-related and community knowledge of the circumstances of the death is minimized. Wide dissemination of accurate drug death surveillance information in an easily accessible and customizable format promotes societal awareness of the drug death epidemic, but also provides information to public health, law enforcement, regulatory, and other community-based organizations that can benefit from the most up-to-date knowledge. We envision a national system of surveillance at the regional ME/C level that would allow for optimal information dissemination and sharing. Such a system would likely allow for more efficacious allocation of resources at the regional and national level.

Nurses' perceptions of caring for parents of children with chronic medical complexity in the pediatric intensive care unit.

OBJECTIVES: The aim of this study was to explore nurses' perceptions of caring for parents of children with medical complexity [CMC] in the pediatric intensive care unit [PICU]. RESEARCH METHODOLOGY: An interpretive descriptive design was used to explore nurses' perceptions of caring for parents of CMC in the PICU. Semi-structured interviews were conducted with ten nurses. Interview data were collected and analyzed using qualitative inductive content analysis. FINDINGS: Nurses revealed that their experiences of caring for parents of CMC evolved over time as they learned to tailor a caregiving partnership based on trust. Although various circumstances could challenge this partnership, nurses strove to maintain and nurture it through self-reflection and optimal communication. Three themes were identified in the data that captured PICU nurses' perceptions: (i) "Thrown to the wolves": Adjusting to a new caregiving role; (ii) "Getting to know each other": Merging caregiving roles; (iii) "Keeping connected": Working to preserve the partnership. CONCLUSIONS: Findings shed new light on the importance of a trusting nurse-parent partnership in caring for parents of CMC in the PICU. Results will be used to develop strategies to enhance this partnership, with the goal of supporting parents and staff in their caregiving roles.

Patterns and Trends in Accidental Poisoning Deaths: Pennsylvania's Experience 1979-2014.

INTRODUCTION: The purpose of this study was to examine county and state-level accidental poisoning mortality trends in Pennsylvania from 1979 to 2014. METHODS: Crude and age-adjusted death rates were formed for age group, race, sex, and county for accidental poisonings (ICD 10 codes X40-X49) from 1979 to 2014 for ages 15+ using the Mortality and Population Data System housed at the University of Pittsburgh. Rate ratios were calculated comparing rates from 1979 to 2014, overall and by sex, age group, and race. Joinpoint regression was used to detect statistically significant changes in trends of age-adjusted mortality rates. RESULTS: Rate ratios for accidental poisoning mortality in Pennsylvania increased more than 14-fold from 1979 to 2014. The largest rate ratios were among 35-44 year olds, females, and White adults. The highest accidental poisoning mortality rates were found in the counties of Southwestern Pennsylvania, those surrounding Philadelphia, and those in Northeast Pennsylvania near Scranton. CONCLUSIONS: The patterns and locations of accidental poisoning mortality by race, sex, and age group provide direction for interventions and policy makers. In particular, this study found the highest rate ratios in PA among females, whites, and the age group 35-44.

Correction: Patterns and Trends in Accidental Poisoning Deaths: Pennsylvania's Experience 1979-2014.

[This corrects the article DOI: 10.1371/journal.pone.0151655.].