The Toxicology Investigators Consortium 2023 Annual Report.

Since 2010, the American College of Medical Toxicology (ACMT) Toxicology Investigators Consortium (ToxIC) has maintained the ToxIC Core Registry, a national case registry of in-hospital and clinic patient consultations submitted by medical toxicology physicians. Deidentified patient data entered into the registry includes patient demographics, reason for medical toxicology evaluation, exposure agents, clinical signs and symptoms, treatments and antidotes administered, and mortality. This fourteenth annual report provides data from 7392 patients entered into the Core Registry in 2023 by 36 participating sites comprising 61 distinct healthcare facilities, bringing the total case count to 102331 between 2010 and 2023. Ethanol was the most commonly reported exposure agent class (24.4%), followed by opioids (22.7%), non-opioid analgesics (16.7%), and antidepressants (11.7%). For the first time since the registry's initiation, in 2023, ethanol was the leading agent of exposure. There were 98 fatalities (case fatality rate of 1.3%). Additional descriptive analyses in this annual report were conducted to describe the reasons for medical toxicology consultation by age in 2023, and yearly trends for opioid and psychoactive exposures, physostigmine and rivastigmine treatments, and acetaminophen exposures treated with fomepizole.

Neonatal and Maternal Ichthyosiform Dermopathy in Association with Kava Use during Pregnancy.

INTRODUCTION: Kava, a substance derived from the Piper methysticum plant, is enjoying a surge in popularity in the United States due to its purported anxiolytic and analgesic effects. Though ichthyosiform dermopathy is a known adverse effect associated with chronic kava exposure in adults, dermopathy in a newborn due to maternal kava use has not yet been described. CASE REPORT: This is a case of a 41-year-old woman who was taking a combination kava/kratom product throughout her pregnancy. She developed an ichthyosiform dermopathy that resolved after she stopped using the product postpartum. Her male infant had a neonatal course complicated by both neonatal opioid withdrawal syndrome, attributed to maternal kratom and buprenorphine use, as well as a diffuse ichthyosiform rash similar to descriptions of kava ichthyosiform dermopathy in adults. His neonatal course was complicated by Group B streptococcus and Serratia marscecens bacteremia (treated with antibiotics) and seizures (treated with lorazepam and phenobarbital). His rash resolved completely by day of life 22. At 9-month outpatient follow-up, he had no dermatologic abnormalities or rash recurrence. DISCUSSION: Maternal kava use during pregnancy may cause fetal dermopathy presenting as an acquired ichthyosis. More public education is needed about the potential consequences of kava use, particularly during pregnancy.

Completeness and Spin of medRxiv Preprint and Associated Published Abstracts of COVID-19 Randomized Clinical Trials.

This study examines publication timelines, completeness, and spin in the abstracts of all randomized clinical trials related to COVID-19 posted to medRxiv during the first 2 years of the pandemic and compared the latter 2 with their published counterparts.

Failure of Crotalidae Immune F(ab')2 Equine Antivenom to Achieve Control in a Southern Pacific Rattlesnake Envenomation.

Rattlesnake envenomation can result in significant cutaneous and hematologic toxicity. While Cotalidae polyvalent immune Fab (ovine) antivenom (marketed as CroFab) was available for years, it is associated with increased late hematologic toxicity compared with its predecessor. Consequently, Crotalidae Immune F(ab')2 equine antivenom [marketed as Anavip; F(ab')2AV] has been recently become available. In this paper, we report a case of a 53 year-old man envenomated on his right hand by a Southern Pacific rattlesnake (Crotalus helleri). Edema was present, and his initial platelets were not able to be measured, prompting the administration of 10 vials of F(ab')2AV. Ultimately, he received a total of 52 vials of antivenom, before his platelets peaked at 102,000/µL, 56 hours post envenomation. Within hours, his platelets began to fall again. Ultimately, his platelets reached a post-antivenom nadir of 65,000/µL. He was observed closely as an outpatient without additional antivenom, and ultimately had normalization of his platelets (211,000/µL) 20 days post envenomation. This case is one of the first cases demonstrating an inability to achieve control of the hematologic toxicity following Southern Pacific rattlesnake envenomation after treatment with F(ab')2AV.

Symptoms and Physical Exam Findings in Sexual Assault-related Non-fatal Strangulation.

OBJECTIVE: Our goal was to investigate the frequency of specific signs and symptoms following sexual assault-related non-fatal strangulation (NFS) and to explore the interaction between assault characteristics and physical exam findings. METHODS: This retrospective observational study included all adults (>18 years) reporting strangulation during sexual assault who presented for a forensic sexual assault exam at one of six urban community hospitals contracted with a single forensic nurse agency. Demographic information, narrative elements, and physical exam findings were abstracted from standardized sexual assault reporting forms. We analyzed data with descriptive statistics and compared specific variables using chi-square testing. RESULTS: Of the 580 subjects 99% were female, with a median age of 27 (interquartile range 22-35 years). The most common injury location was the neck (57.2%), followed by the mouth (29.1%). We found that 19.1% of the victims had no injuries evident on physical exam and 29.8% reported a loss of consciousness. Eye/eyelid and neck findings did not significantly differ between subjects who reported blows to the head in addition to strangulation and those who did not. The time that elapsed between assault and exam did not significantly correlate with the presence of most head and torso physical exam findings, except for nose injury (P = 0.02). CONCLUSION: Slightly more than half of the victims who reported strangulation during sexual assault had visible neck injuries. Other non-anogenital findings were present even less frequently, with a substantial portion of victims having no injuries documented on physical exam. The perpetrators' use of blows to the head may account for many of the non-anogenital injuries observed, but not for the neck and eye/eyelid injuries, which may be more specific to non-fatal strangulation. More research is needed to definitively establish strangulation as the causal mechanism for these findings, and to determine whether any long-term neurologic or vascular sequelae resulted from the observed injuries.

Uveal Melanoma Identified as Ocular Mass on Point-of-care Ultrasound.

CASE PRESENTATION: A 41-year-old man presented to the emergency department with five months of progressive monocular vision loss in his right eye, which he described as a gradually descending and enlarging black spot. He had no light perception in his right eye with elevated intraocular pressure and an afferent pupillary defect, while his left eye visual acuity and pupillary exam was normal. Point-of-care ultrasound demonstrated a hyperechoic, pedunculated mass in the posterior chamber of his right eye, consistent with a diagnosis of ocular melanoma. Ophthalmology scheduled the patient for an elective, right eye enucleation the following week, after which a diagnosis of uveal melanoma (UM) was confirmed on histopathology. DISCUSSION: Uveal melanoma is an uncommon diagnosis that requires prompt intervention and surveillance due to the possibility of distant metastases arising in up to 50% of patients. Emergency department diagnosis of UM may be confounded by features of other intraocular pathology, such as increased ocular pressure or the finding of retinal detachment on fundoscopy. When emergency providers encounter glaucoma or retinal detachment on physical exam, point-of-care ultrasonography represents a key adjunct in the timely diagnosis and referral of this potentially vision- and life-threatening malignancy.