Characteristics of analytically confirmed gamma-hydroxybutyrate (GHB) positive patients in the emergency department: presentation, poly-drug use, disposition and impact on intensive care resource utilisation.

BACKGROUND: Gamma-hydroxybutyrate is a potent central nervous system depressant with a narrow recreational dose window and analytical detection time. We describe data relating to intoxicated patients presenting to emergency departments across metropolitan Adelaide who tested positive for gamma-hydroxybutyrate. This work was part of the Emergency Department Admission Blood Psychoactive Testing study. METHODS: Over a 15-month period, patients presenting to four metropolitan emergency departments with symptoms of drug intoxication were enrolled in the study. The methodology involved the collection of demographic and clinical data and a de-identified blood sample which underwent comprehensive toxicological analysis. Gamma-hydroxybutyrate was determined using an acid-catalysed cyclisation followed by liquid-liquid extraction and gas chromatography-mass spectrometry. Data relating to samples positive for gamma-hydroxybutyrate were examined. RESULTS AND DISCUSSION: A total of 1120 patients were enrolled between March 2019 and May 2020, 309 of whom were positive for gamma-hydroxybutyrate (27.6%). Of these, 256 (83%) were also positive for metamfetamine (methamphetamine). The most common clinical observation in gamma-hydroxybutyrate-positive patients was central nervous system depression (89%). There was a significant relationship between gamma-hydroxybutyrate status and sex; although males outnumbered females in absolute terms, a higher proportion of females (32%) tested positive for gamma-hydroxybutyrate than males (25%, P = 0.0155). Blood gamma-hydroxybutyrate concentrations ranged from 10 to 651 mg/L (0.096-6.2 mmol/L) and increasing gamma-hydroxybutyrate concentration correlated with severe toxicity. The presence of gamma-hydroxybutyrate had a significant impact on the patient discharge destination: the majority (69.2%) of gamma-hydroxybutyrate-positive patients were managed and discharged from the emergency department or their attached short stay wards. A significantly higher proportion of gamma-hydroxybutyrate-positive patients were admitted to the intensive care unit (28.2%) compared with gamma-hydroxybutyrate-negative patients (12.7%, chi-squared = 36.85, P <0 .001). Gamma-hydroxybutyrate positive cases accounted for 45.8% of all study-related intensive care unit admissions. CONCLUSIONS: Gamma-hydroxybutyrate is commonly detected in illicit drug-related emergency department presentations and is detected disproportionately in the patient cohort who require intensive care unit level care.

Home Away from Home: Comparing Factors Impacting Migrants' and Italians Sense of Psychological Home.

Psychological home is an understudied concept within community psychology, especially focused on migrants. Previous literature on psychological home found a positive relationship with well-being and resilience in general populations and migrants. Studying psychological home in migrants may provide important tools to buffer various stresses associated with migration. The present study explored the relationship between psychological home and demographic factors, including dwelling type and situation between migrants (n = 132) and Italian citizens' population (n = 76). Results offer theoretical reasons explaining the differences in the meaning of home between migrant and non-immigrant populations.

Delivering harm reduction to the community and frontline medical practitioners through the South Australian Drug Early Warning System (SADEWS).

Australia does not have a formal drug early warning system. A coordinated program of fixed or event-based drug-checking is expensive and provides harm reduction information to atargeted user group. The South Australian Drug Early Warning System (SADEWS) is an informal inter-agency collaboration which rapidly and confidentially exchanges contemporary,evidence-based information about drug seizures, usage trends and clinical outcomes associated with drug use in South Australia. Information is sourced from policing, forensic analysis,waste-water analysis, medical research, clinical data and directly from people using drugs. SADEWS exchanges information relating to new drug emergences and clusters of adverseoutcomes following drug use, amongst members via secure digital platforms. The diverse but complimentary expertise of members allows a comprehensive assessment of changes tothe baseline risk associated with drug use and, where a potential community harm is identified, enables the timely delivery of warnings through formal mechanisms existing withinmember agencies. It is expected that these warnings contribute to significantly reduced medical consequences associated with community drug use through decreased drug overdosefatalities and hospital presentations rates, contributing to reduced healthcare costs. Importantly, this drug early warning system is politically risk-free, is achieved simply and without external funding or significant administrative overheads.

Establishing the protocols for the South Australian Emergency Department Admission Blood Psychoactive Testing (EDABPT) programme for drug surveillance.

OBJECTIVE: ED presentations because of illicit use of psychotropic drugs and pharmaceuticals result in significant medical harm and resource consumption. Patient assessment is complicated by the regular emergence of new psychoactive substances, difficulties associated with their identification and a lack of information about their effects. Here we report the protocol for the Emergency Department Admission Blood Psychoactive Testing (EDABPT) programme, an observational study utilising clinical data capture and definitive drug identification to assess the medical impact and patterns of illicit drug use in the community, and their geographic and temporal fluctuations. The study provides data to an early warning system targeting an improved public health response to emerging drugs of concern. METHODS: Enrolment of adult patients presenting with suspected illicit drug use occurs at four major EDs in a single urban setting. Clinical and demographic data are collected by treating clinicians. Blood samples are collected at presentation and frozen on site prior to transport to a specialised forensic facility for comprehensive toxicological screening. RESULTS: Results are fed back to clinicians and disseminated more broadly via an existing local early warning system. Targeted warnings and public health releases are instigated where heightened risk or harm is identified. CONCLUSION: The study pairs city-wide patient enrolment with analytically confirmed toxicology results to allow broad sampling and identification of illicit drugs causing medical harm. It provides a mechanism for the identification of new agents as they emerge in the community, delivers a relevant and reliable source of information for public health agencies and clinicians and supplements existing local early warning mechanisms.

Nationwide randomised trial evaluating elective neck dissection for early stage oral cancer (SEND study) with meta-analysis and concurrent real-world cohort.

BACKGROUND: Guidelines remain unclear over whether patients with early stage oral cancer without overt neck disease benefit from upfront elective neck dissection (END), particularly those with the smallest tumours. METHODS: We conducted a randomised trial of patients with stage T1/T2 N0 disease, who had their mouth tumour resected either with or without END. Data were also collected from a concurrent cohort of patients who had their preferred surgery. Endpoints included overall survival (OS) and disease-free survival (DFS). We conducted a meta-analysis of all six randomised trials. RESULTS: Two hundred fifty randomised and 346 observational cohort patients were studied (27 hospitals). Occult neck disease was found in 19.1% (T1) and 34.7% (T2) patients respectively. Five-year intention-to-treat hazard ratios (HR) were: OS HR = 0.71 (p = 0.18), and DFS HR = 0.66 (p = 0.04). Corresponding per-protocol results were: OS HR = 0.59 (p = 0.054), and DFS HR = 0.56 (p = 0.007). END was effective for small tumours. END patients experienced more facial/neck nerve damage; QoL was largely unaffected. The observational cohort supported the randomised findings. The meta-analysis produced HR OS 0.64 and DFS 0.54 (p < 0.001). CONCLUSION: SEND and the cumulative evidence show that within a generalisable setting oral cancer patients who have an upfront END have a lower risk of death/recurrence, even with small tumours. CLINICAL TRIAL REGISTRATION: NIHR UK Clinical Research Network database ID number: UKCRN 2069 (registered on 17/02/2006), ISCRTN number: 65018995, ClinicalTrials.gov Identifier: NCT00571883.

A risk-based approach to cognitive bias in forensic science.

Over the past decade, the potential impact of cognitive bias in forensic science has instigated much discussion and debate between academics, scientists and those in the justice sector. Evidence of bias influencing subjective decision-making across a range of forensic disciplines has been described in the literature. Forensic service organisations are being urged to address cognitive bias in subjective decision-making by designing processes or procedures to limit access to (irrelevant) contextual information or reduce dependence on cognitive functions. Although some laboratories have implemented bias mitigating strategies, with varying impact on operational efficiency, there has been no systematic assessment of the risk posed by cognitive bias. Forensic Science SA assessed the potential impact of bias on forensic interpretations across multiple disciplines, using a risk management framework. This process proved useful in assessing the effectiveness of existing bias mitigating strategies and identified the latent level of risk posed. While all forensic organisations should seek to implement bias limiting measures that are simple, cost-effective and do not adversely impact efficiency, using a risk-based approach has contextualised the limited benefit of introducing resource hungry measures, as postulated in the literature. That is not to suggest that forensic organisations should dismiss the potential influence of cognitive bias but they need to strike an appropriate balance between risk and return, as they do with any business risk.

Sinus pericranii--"Don't judge a lump by its surface".

An interesting and unusual vascular malformation, sinus pericranii is presented. Originally referred as a cyst, a "community conundrum" was solved and treated successfully in the hospital setting. A discussion of sinus pericranii follows, and the teaching values of this particular case are highlighted.

Chemical analysis of four capsules containing the controlled substance analogues 4-methylmethcathinone, 2-fluoromethamphetamine, alpha-phthalimidopropiophenone and N-ethylcathinone.

In August 2007, four capsules containing white powders, said to have originated from an Israel-based Internet company "Neorganics", were anonymously delivered to the Royal Adelaide Hospital, South Australia. The capsules were analysed and the active components were identified including 4-methylmethcathinone, 2-fluoromethamphetamine, alpha-phthalimidopropiophenone and N-ethylcathinone, all of which were unlisted within South Australian controlled substance regulations. We examined the relevant scientific literature surrounding these chemicals and present both GCMS and NMR data for 4-methylmethcathinone and alpha-phthalimidopropiophenone, which have previously received little attention. We also present the vapour- and condensed-phase infrared spectra (IR) of 4-methylmethcathinone as these have also not been reported in the literature previously. We discuss the issues surrounding whether these chemicals can be classified as controlled substance analogues and the likely impact this could have on prosecutions of individuals distributing these products.

Non-traumatic nasal septal abscess in an immunocompetent patient.

Nasal septal abscess is an uncommon condition. Most commonly it is secondary to nasal trauma, which leads to haematoma, and subsequent abscess formation. There are other less common causes like sinusitis, dental infections and furunculosis. Non-traumatic nasal septal abscess has also been reported in immunocompromised individuals. We report a case of non-traumatic, spontaneous nasal septal abscess, in a healthy immunocompetent patient with no evidence of sinusitis or other localized infections. Using Medline and Google.co.uk search applications, there has been one previous report of such a condition. We stress the importance of excluding nasal septal abscess in patients presenting with nasal obstruction especially with signs of toxaemia.

Optimizing local anesthesia for grommet insertion: eutectic mixture of local anaesthetics versus Ametop: a randomized clinical trial.

OBJECTIVE: To compare the effect of eutetic mixture of local anesthetics (EMLA) with Ametop in providing local anesthesia for grommet insertion. STUDY DESIGN: Double-blind randomized clinical trial. SETTING: University teaching hospital. PATIENTS: Forty-one adult patients diagnosed with otitis media with effusion were recruited into the trial and underwent grommet insertion under local anesthesia; 21 were randomly allocated to the EMLA group and 20 to the Ametop group. MAIN OUTCOME MEASURES: The primary outcome measure of the study was the level of pain experienced by the patient. The secondary outcome measure was the overall satisfaction with the procedure. Both measures were assessed using visual analogue scales. RESULTS: Both the topical anesthetic agents provided good pain relief during grommet insertion. There was no statistically significant difference in the pain or satisfaction scores. CONCLUSION: Both EMLA and Ametop can provide good local anesthetic effect during grommet insertion.

Underground pill testing, down under.

At a recent South Australian rave, results reported to users from on-site pill-testing, using pill-testing kits, were compared with GCMS analysis of a scraping from the same pill. The presence of an ecstasy-like substance or methylamphetamine was correctly reported to users in 100% of pills that contained those substances. However only 11% of pills with combinations of illicit substances had both substances correctly identified. Ketamine was particularly problematic with identification occurring in only 18% of pills and in some instances, the colorimetric response obtained from ketamine was confused with the response from methylamphetamine. This study also allowed a comparison between pill design and composition encountered at the rave with those submitted to the forensic laboratory over a 6-month period including the month the rave was held. MDMA was present in 68% of pills at the rave and 89% of pills submitted by the police. Ketamine was present in 27 and 26% of pills, respectively and was often combined with other substances. The combinations of illicit substances were identical apart from one police-pill seizure that contained MDMA combined with PMA. This combination has not been previously encountered in South Australia. The pill designs observed at the rave differed significantly from the designs on pills submitted for testing by police. These differences limit the use of pill comparison charts as an alternative identification tool to colorimetric pill testing in South Australia.