Hands-Free Analytical Urine Testing Technology Validated for Drug-Facilitated Crime Investigations.

Forensic laboratories need quick and simple technology to improve turnaround times, while delivering reliable results. The goal of this study is first to create a simplified workflow to meet new Academy Standards Board requirements for urine testing in drug-facilitated crime investigations and, second, to create "ready-to-go", "hands-free" testing technology to further streamline analytical procedures. A first of its kind, the ToxBox forensic test kit is used to validate a single analytical procedure for opioids, benzodiazepines, cannabinoids, antidepressants, and several other drug classes. Method performance indicators follow accreditation requirements and include accuracy, precision, measurement uncertainty, calibration models, reportable range, sensitivity, specificity, carryover, interference, ion suppression/enhancement, and analyte stability. "Hands-free" testing platforms require the use of new suspended-state technology to stabilize NIST-traceable standards premanufactured at precise concentrations in the presence of sample preparation reagents. By suspending all reaction components in the solid state, with air gaps between the phases, reference standards and process controls are built in a "ready-to-go" format and stabilized for long-term storage in the presence of a sample matrix, ß-d-glucuronidase, and enzymatic buffers. "Hands-free" test kits are removed from storage, incubated at either ambient temperature or 60 °C, and assayed using validated methods. This is the first example of how complex forensic testing workflows can be streamlined with new "hands-free" testing strategies to meet analytical challenges associated with quantitative and confirmatory analyses.

Synthetic cannabinoid poisonings and access to the legal cannabis market: findings from US national poison centre data 2016-2019.

AIM: To investigate trends in synthetic cannabinoid exposures reported to United States (US) poison control centres, and their association with status of state cannabis legalisation. METHODS: A retrospective study of National Poison Data System (NPDS) data from 2016 to 2019 identified and associated synthetic poisoning reports with annual state cannabis law and market status. State status was categorised as restrictive (cannabis illegal or limited medical legalisation), medical (allowing THC-containing medical cannabis use) and permissive (allowing non-medical use of THC-containing cannabis by adults). We categorised a subset of states with permissive policies by their implementation of legal adult possession/use and opening retail markets, on a quarterly basis. Mixed-effects Poisson regression models assessed synthetic exposures associated with legal status, first among all states using annual counts, and then among states that implemented permissive law alone using quarterly counts. RESULTS: A total of 7600 exposures were reported during the study period. Overall, reported synthetic exposures declined over time. Most reported exposures (64.8%) required medical attention, and 61 deaths were documented. State implementation of medical cannabis law was associated with 13% fewer reported annual exposures. Adoption of permissive state cannabis policy was independently and significantly associated with 37% lower reported annual synthetic exposures, relative to restrictive policies (IRR: 0.63, 95% CI: 0.50-0.79). Among states with permissive law during the period, implementation of legal adult possession/use was associated with 22% fewer reported quarterly exposures. Opening of retail markets was associated with 36% fewer reported exposures, relative to states with medical cannabis only. CONCLUSIONS: Adoption of permissive cannabis law was associated with significant reductions in reported synthetic cannabinoid exposures. More permissive cannabis law may have the unintended benefit of reducing both motivation and harms associated with use of synthetic cannabis products.

Methylene Blue: An Antidote for Methemoglobinemia and Beyond.

ABSTRACT: Methylene blue has been in medicinal use for centuries and is best known as an antidotal treatment for acquired methemoglobinemia (MetHB). More recently, methylene blue has gained recognition for its efficacious use in the treatment of ifosfamide neurotoxicity and refractory vasoplegic shock in both the pediatric and adult critical care literature, extending its use beyond MetHB. Methylene blue's mechanism of action is somewhat complex and based partly on its oxidizing capabilities, ironically the same mechanism that causes MetHB. This review will examine methylene blue's use in the treatment of acquired MetHB and ifosfamide neurotoxicity and review the current literature regarding its role in critically ill pediatric and adult patients with refractory vasoplegic shock. Methylene blue's pharmacologic actions, dosing, and adverse effects will also be discussed.

Adverse Effects and Toxicity of the Atypical Antipsychotics: What is Important for the Pediatric Emergency Medicine Practitioner.

Medications are being used with greater frequency to address pediatric mental health problems, and in recent years atypical antipsychotic (AAP) prescriptions have increased more than any other class. Acute care practitioners must be aware of the pharmacology of AAPs and the conditions, on- and off-label, for which they are prescribed. This involves identifying and managing side effects that manifest both mentally and physically. Although "atypicality" confers a lower risk of movement side effects compared to conventional agents, children are more sensitive than adults to extrapyramidal reactions. Like adults, they also may present with toxic sedation, confusion, cardiovascular dysfunction, and metabolic derangements. Evaluation and management of these toxicities requires an index of suspicion, a careful symptom and medication history, physical examination, and targeted interventions. This review is designed to orient the emergency practitioner to the challenging task of recognizing and treating adverse effects related to acute and chronic atypical antipsychotic exposure in children.

Enhancing patient safety in the pediatric emergency department: teams, communication, and lessons from crew resource management.

The fast-paced and multifaceted nature of patient care in the emergency department makes our discipline especially prone to errors and adverse events. In recent years, strategies such as formal communication and medical team training have been proposed as potential means to enhance patient safety. In many ways, practice dynamics particular to the emergency department make this setting almost ideal for implementation of these strategies. This article reviews concepts of communication and team training in medicine, including those learned from the aviation industry (known as crew resource management). Recent literature pertaining to teams and communication in medicine is reviewed.

Voluntarily reported unintentional injections from epinephrine auto-injectors.

BACKGROUND: Epinephrine auto-injectors provide life-saving prehospital treatment for individuals experiencing anaphylaxis in community settings. OBJECTIVE: To determine the number, demographics, and associated circumstances and outcomes of unintentional injections from epinephrine auto-injectors. METHODS: We searched the databases of the American Association of Poison Control Centers and the Food and Drug Administration's Safety Information and Adverse Event Report System for these incidents as reported by members of the public and by health care professionals. RESULTS: From 1994 to 2007, a total of 15,190 unintentional injections from epinephrine auto-injectors were reported to US Poison Control Centers, 60% of them from 2003 to 2007. Those unintentionally injected had a median age of 14 years (interquartile range, 8-35), 55% were female, and 85% were injected in a home or other residence. Management was documented in only 4101 cases (27%), of whom 53% were observed without intervention, 29% were treated, 13% were neither held for observation nor treated, and 4% refused treatment. In contrast, from 1969 to 2007, only 105 unintentional injections from epinephrine auto-injectors were reported to MedWatch. Forty percent of these occurred during attempts to treat allergic reactions. Injuries resulting in permanent sequelae were rarely reported to either US Poison Control Centers or to MedWatch. CONCLUSION: The number of reported unintentional injections from epinephrine auto-injectors increased annually from 1994 to 2007. To prevent these unintentional injections, improved epinephrine auto-injector design is needed, along with increased vigilance in training the trainers and in training and coaching the users, as well as efforts to increase public awareness of the role of epinephrine auto-injectors in the first-aid treatment of anaphylaxis in the community.

Alternating antipyretics for fever reduction in children: an unfounded practice passed down to parents from pediatricians.

A convenience sample of parents/caregivers completed a 10-question survey on their patterns of antipyretic therapy administration to determine if antipyretics were alternated, how often, who advised them to do this, and how they learned to dose the antipyretic. Of the 256 caregivers (93%) who completed the survey, 67% responded that they alternated acetaminophen and/or ibuprofen. The frequency varied: every 2 hours (9%), every 3 hours (16%), every 4 hours (43%), every 6 hours (23%) and other (8%). Of these, 81% stated that their health care provider/pediatrician advised them to alternate acetaminophen and/or ibuprofen; 8% stated that nobody advised them. Only 61% received written instructions on how to dose antipyretics from their health care provider. Most caregivers of young children reported alternating acetaminophen and ibuprofen for fever reduction in their children. There was a wide variability of the dosing interval. Most learned this practice from their pediatrician/health care provider.

Update on antidotes for pediatric poisoning.

Antidotes are playing an increasing role in therapy for pediatric poisonings. Although initial response to all pediatric poisonings begins with basic stabilization, knowledge of specific antidotes, their mechanisms of action, safety profile in pediatrics, and dosing regimens can be life-saving for pediatric victims of nerve gas exposure, acetaminophen toxicity, methanol and ethylene glycol ingestion, and snakebites. This article presents an overview of the pathophysiology, symptoms, antidotes, and emergency management of these toxicological emergencies.