Shifting the paradigm: physician-authorized, student-led efforts to provide harm reduction services amidst legislative opposition.

BACKGROUND: For over 30 years, syringe services programs (SSPs) have served as an efficacious intervention for the prevention of HIV and Hepatitis C transmission among persons who use drugs. Despite a strong body of evidence for the effectiveness of SSPs as a preventative public health measure, numerous local and state governments in the United States continue to resist the establishment of new SSPs and aggressively pursue the closure of those already in operation. COMMENTARY: In Orange County, California, local officials have repeatedly mobilized in opposition of the establishment of syringe access - thereby hindering access to healthcare for thousands of predominantly unhoused individuals. The county was previously served by the Orange County Needle Exchange Program from 2016 until 2018 when a civil suit brought by the Orange County Board of Supervisors resulted in the closure of the program. For more than 2 years, persons who inject drugs in Orange County lacked reliable access to clean syringes, placing them at increased risk for contracting HIV and Hepatitis C. Here, we comment on the ongoing effort to restore syringe access in Orange County. This collaborative physician-directed endeavor has brought together students and community volunteers to provide vital harm reduction services to a remarkably underserved population. Since the reestablishment of syringe access in Orange County by the Harm Reduction Institute, new legal barriers have arisen including the passage of new municipal legislation banning the operation of syringe exchanges. We are well-equipped to overcome these obstacles. This work serves as an affirmation of assertions made by previous authors regarding the unique qualifications of medical & graduate students as effective harm reductionists. CONCLUSION: Harm reduction services are vital to the health and well-being of people who use drugs. The provision of these services should not be impeded by legislative interference by municipal, county, or state governments.

Negligible Oleandrin Content of Hot Dogs Cooked on Nerium oleander Skewers.

INTRODUCTION: The Nerium oleander plant contains cardenolides that may cause human poisoning when ingested. A long-standing belief holds that it is possible to be poisoned by eating hot dogs or other foods cooked on Nerium oleander branch skewers. Oleandrin levels in frankfurters cooked on fresh and dry Nerium oleander skewers were measured. METHODS: Hot dogs were cooked separately on either dried or fresh oleander branch skewers using a disposable charcoal grill. The hot dogs were then frozen and transported to an analytical laboratory where oleandrin content was measured via liquid chromatography/mass spectroscopy (LC/MS). RESULTS: The oleandrin content of hot dogs cooked on dried and fresh skewers did not exceed 343 ng and 701 ng, respectively. CONCLUSION: Hot dogs cooked on Nerium oleander skewers contain a negligible amount of oleandrin with respect to that sufficient to cause human poisoning. Reports of poisonings occurring in this manner are most likely the result of an urban myth.

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.

Fatalities due to dichloromethane in paint strippers: a continuing problem.

BACKGROUND: Exposure to dichloromethane (DCM or methylene chloride - CH2 Cl2 ) in paint strippers continues to be an avoidable source of morbidity and mortality. DCM has been under regulatory scrutiny by occupational and consumer product agencies since the identification of its carcinogenicity in the mid-1980s. METHODS: We investigated two independent workplace incidents that resulted in three cases of DCM intoxication from paint stripper use. RESULTS: Each incident investigated resulted in a fatality. A third worker suffered obtundation requiring hospitalization and intubation. CONCLUSIONS: The continued occurrence of fatalities and other serious injuries due to DCM-containing paint strippers in the United States calls for a re-evaluation of existing regulatory strategies.

"Spider bite" lesions are usually diagnosed as skin and soft-tissue infections.

BACKGROUND: Many people seek medical attention for skin lesions and other conditions they attribute to spider bites. Prior experience suggests that many of these lesions have alternate causes, especially infections with community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA). OBJECTIVES: This study determined the percentage of emergency department (ED) patients reporting a "spider bite" who received a clinical diagnosis of spider bite by their physician vs. other etiologies, and if the diagnoses correlated with demographic risk factors for developing CA-MRSA infections. METHODS: ED patients who reported that their condition was caused by a "spider bite" were prospectively enrolled in an anonymous, voluntary survey regarding details of their illness and demographic information. Discharge diagnoses were also collected and categorized as: spider bite, bite from other animal (including unknown arthropod), infection, or other diagnosis. RESULTS: There were 182 patients enrolled over 23 months. Seven patients (3.8%) were diagnosed with actual spider bites, 9 patients (4.9%) with bites from other animals, 156 patients (85.7%) with infections, and 6 patients (3.3%) were given other diagnoses. Four patients were given concurrent diagnoses in two categories, and 8 (4.4%) did not have the diagnosis recorded on the data collection instrument. No statistically significant associations were found between the patients' diagnostic categories and the demographic risk factors for CA-MRSA assessed. CONCLUSION: ED patients reporting a "spider bite" were most frequently diagnosed with skin and soft-tissue infections. Clinically confirmed spider bites were rare, and were caused by black widow spiders when the species could be identified.

1,4-Butanediol content of aqua dots children's craft toy beads.

INTRODUCTION: The U.S. Consumer Product Safety Commission announced a recall of Aqua Dots (Spin Master Ltd.; Toronto, Canada) on November 7, 2007 due to children becoming ill after swallowing beads from these toy craft kits. Reports suggested that the beads contained 1,4-butanediol (1,4-BD), a precursor to gamma-hydroxybutyrate (GHB), rather than the intended, but more expensive 1,5-pentanediol (1,5-PD). We measured the 1,4-BD and 1,5-PD content of Aqua Dots beads to determine if 1,5-PD had been completely substituted with 1,4-BD by the manufacturer, and if the reported clinical effects from swallowing Aqua Dots beads were consistent with the estimated ingested 1,4-BD dose. METHODS: In vitro bench research using gas chromatography-mass spectroscopy (GC-MS) was performed. Dilute samples of pure 1,4-BD and 1,5-PD in water were used for the calibration of the GC-MS instrument. We then soaked Aqua Dots beads in water for varying durations, and the resultant solutions were analyzed for 1,4-BD and 1,5-PD content. RESULTS: Aqua Dots beads weighed 79.3 mg each (+/- 0.6 mg, SD), and contained 13.7% (+/- 2.4%, SD) 1,4-BD by weight; this corresponds to a 1,4-BD content of 10.8 mg (+/- 1.9 mg, SD) per bead. No 1,5-PD was detected in any beads. CONCLUSIONS: Aqua Dots beads contained a surprisingly high amount (nearly 14%) of extractable 1,4-BD. No 1,5-PD was detected, corroborating reports that this chemical had been completely replaced with a substitute that is metabolized into GHB after ingestion. Reports of ataxia, vomiting, seizure activity, and self-limited coma in children are consistent with the ingestion of several dozen Aqua Dots beads.

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.

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 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.

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.