Robert D. Cox

Severe Illness Associated with Reported Use of Synthetic Cannabinoids - Mississippi, April 2015.

On April 2, 2015, four patients were evaluated at the University of Mississippi Medical Center (UMMC) in Jackson, Mississippi, for agitated delirium after using synthetic cannabinoids. Over the next 3 days, 24 additional persons went to UMMC with illnesses suspected to be related to synthetic cannabinoid use; one patient died. UMMC notified the Mississippi State Department of Health, which issued a statewide alert via the Health Alert Network on April 5, requesting that health care providers report suspected cases of synthetic cannabinoid intoxication to the Mississippi Poison Control Center (MPCC). A suspected case was defined as the occurrence of at least two of the following symptoms: sweating, severe agitation, or psychosis in a person with known or suspected synthetic cannabinoid use. A second statewide alert was issued on April 13, instructing all Mississippi emergency departments to submit line lists of suspected patients to MPCC each day. By April 21, 16 days after the first alert was issued, MPCC had received reports of approximately 400 cases, including eight deaths possibly linked to synthetic cannabinoid use; in contrast, during April 2012–March 2015, the median number of telephone calls to MPCC regarding synthetic cannabinoid use was one per month (range = 0–11). The Mississippi State Department of Health, with the assistance of CDC, initiated an investigation to better characterize the outbreak, identify risk factors associated with severe illness, and prevent additional illnesses and deaths.

Injuries sustained during competitive white-water paddling: a survey of athletes in the 1996 Olympic trials

To examine injury prevalence in competitive paddlers, a cross-sectional, retrospective, written survey of the athletes competing in the four regional Olympic canoe and kayak qualifying races for the United States Canoe and Kayak Team was conducted in the spring of 1996. A total of 375 questionnaires were distributed, of which 54 were completed and returned. Results were reported as the percentage of total injuries. A composite of 271 separate injuries was reported by kayakers during their careers. While 56% of the injuries occurred during training, 40% happened during recreation and 4% during competition. The most frequent injuries were sprains (32%), tendonitis (20%), and chronic musculoskeletal pain (14%). Simple bruises (9%) and infections (8%) occurred with moderate frequency, while severe injuries, such as dislocations (3%) and lacerations (2%), were even less common. About 10% of the paddlers noted a near-drowning event during their careers. Of the injuries noted, 70% were reported as recurrent or chronic. Treatment included rest (37%), physical therapy (23%), medical intervention (34%), and surgical intervention (6%). White-water paddling of canoes and kayaks is a potentially dangerous sport, and competitive paddlers frequently suffer a range of injuries. Most injuries occurred during training; however, the short intense work of racing produced a greater frequency of injuries.

Evaluation of the patterns of potentially toxic exposures in Mississippi following Hurricane Katrina

Objective. To describe the changes in the frequency of selected toxic exposures reported to the state poison control center following Hurricane Katrina. Methods. The numbers of selected exposures reported to the Mississippi Poison Control Center at 0–2 weeks, 3–4 weeks, and 5–12 weeks following Hurricane Katrina were compared to those for the same time periods in the previous 3 years. Absolute numbers of exposures and odds ratios with confidence intervals were used for comparison. Results. In the first 2 weeks following Hurricane Katrina, there were 44 reported gasoline exposures compared to 7 expected, 8 lamp oil exposures compared to 1 expected, and seven carbon monoxide exposures compared to 1 expected. Only gasoline exposures remained elevated in the second 2 weeks period following the hurricane. Lamp oil exposures were elevated during the 5–12 week recovery period. There was no increase in the frequency of exposures to household cleaning agents, food poisoning, pediatric exposures, drug-related suicide events, bites and stings, or venomous snakebites. Conclusions. The most common toxic exposures following Hurricane Katrina were related to the lack of typical energy sources, electricity, and gasoline.

Lead Toxicity As an Etiology for Abdominal Pain in the Emergency Department

BACKGROUND Abdominal pain is an uncommon presentation of lead toxicity in the emergency department (ED). However, making the diagnosis is important in avoiding unnecessary testing and the long-term sequelae of lead toxicity. OBJECTIVES To illustrate possible presentations of abdominal pain secondary to lead toxicity and highlight the importance of taking a thorough patient history. CASE REPORT We report 2 patients who presented to the ED with abdominal pain and underwent extensive evaluations that did not reveal an etiology. At follow-up visits, their occupational histories revealed possible lead exposures from working for a bullet-recycling company. Tests revealed that each patient had extremely high lead levels and they were both treated for lead toxicity. Their abdominal pain resolved as their lead levels decreased. CONCLUSION These cases demonstrate a rare but significant cause of abdominal pain in the ED. Although history-taking in the ED is necessarily brief, these cases underscore the importance of obtaining an occupational history.

Evaluation of potential adverse health effects resulting from chronic domestic exposure to the organophosphate insecticide methyl parathion.

Methyl parathion (MP) was used illegally to spray homes for insect control over approximately an 8-yr period. In an attempt to determine if there were any adverse health effects from this, health-screening evaluations were performed on 353 individuals living in homes that were illegally sprayed. The average subject spent 15.5 h a day in the home. Subjects from homes with high levels of MP (exposure group) were compared to controls that lived in homes with minimal or no MP. Subjects were aware of the levels of MP found in their homes and recall bias was likely. There were no significant differences in the symptoms reported or by the physician assessment of subacute or chronic toxicity between those in the exposure group and controls. No significant differences were found in growth and developmental evaluations. Three subjects were identified who most likely suffered acute toxicity from the initial exposure and were not appropriately diagnosed and treated. Cholinesterase determinations also did not differ between those in the exposure group and controls. When subjects from the exposure group were stratified by the level of MP in their home, those from homes with the highest levels appeared to have an increased likelihood of subacute toxicity and reported an increased number of neuropsychiatric symptoms (OR 2 for both evaluations).

Severe illness associated with reported use of synthetic cannabinoids: a public health investigation (Mississippi, 2015)

Abstract Study objectives: In April 2015, a multistate outbreak of illness linked to synthetic cannabinoid (SC) use was unprecedented in magnitude and severity. We identified Mississippi cases in near-real time, collected information on cases to characterize the outbreak, and identified the causative SC. Methods: A case was defined as any patient of a Mississippi healthcare facility who was suspected of SC use and presenting with ≥2 of the following symptoms: sweating, severe agitation, or psychosis during April 2–May 3, 2015. Clinicians reported cases to the Mississippi Poison Control Center (MPCC). We used MPCC data to identify cases at the University of Mississippi Medical Center (UMMC) to characterize in further detail, including demographics and clinical findings. Biologic samples were tested for known and unknown SCs by liquid chromatography quadrupole time-of-flight mass spectrometry (LC-QTOF/MS). Results: Clinicians reported 721 cases (11 deaths) statewide; 119 (17%) were UMMC patients with detailed data for further analysis. Twelve (10%) were admitted to an intensive care unit and 2 (2%) died. Aggression (32%), hypertension (33%), and tachycardia (42%) were common. SCs were identified in serum from 39/56 patients (70%); 33/39 patients (85%) tested positive for MAB-CHMINACA (N-(1-amino-3,3-dimethyl-1-oxobutan-2-yl)-1-(cyclohexylmethyl)-1H-indazole-3-carboxamide) or its metabolites. Compared to all patients tested for SCs, those positive for MAB-CHMINACA were more likely to have altered mental status on examination (OR = 3.3, p = .05). Conclusion: SC use can cause severe health effects. MAB-CHMINACA was the most commonly detected SC in this outbreak. As new SCs are created, new strategies to optimize surveillance and patient care are needed to address this evolving public health threat.

Misidentification of copperhead and cottonmouth snakes following snakebites

Abstract Introduction: Copperhead (Agkistrodon contortrix) and cottonmouth or water moccasin (Agkistrodon piscivorus) snakes account for the majority of venomous snakebites in the southern United States. Cottonmouth snakes are generally considered to have more potent venom. Copperheads are considered less venomous and there is some controversy as to whether or not bites from copperhead snakes need to be treated with antivenom. Copperhead and juvenile cottonmouth snakes are both brown in color. The purpose of this study was to evaluate the accuracy of identification by the public and healthcare providers between these two species. Methods: Snakebite victims sometimes bring dead snakes to the hospital or have taken pictures of the snake. When this occurred, ED personnel were asked to take a picture of the snake, and forward the picture to the state poison control center. The identification of the snake by witnesses and/or hospital personnel was compared to the identification by the state herpetologist. Results: During the study period, there were 286 cases of snakebites reported to the state poison control center. Pictures were obtained on 49 of the responsible snakes. All copperhead snakes were identified correctly by callers. However, only 21% of cottonmouth snakes were identified correctly, with 74% of cottonmouth snakes being identified as copperheads. Both public and medical personnel performed poorly on identification of cottonmouth snakes. Conclusions: Forty percent of the snakes identified as copperheads were actually cottonmouth snakes. Juvenile cottonmouth snakes were often identified as copperhead snakes.

Air Ambulance Delivery and Administration of Four‐factor Prothrombin Complex Concentrate Is Feasible and Decreases Time to Anticoagulation Reversal

OBJECTIVES The objective was to evaluate the feasibility, safety, and preliminary efficacy of four-factor prothrombin complex concentrate (4-factor PCC) administration by an air ambulance service prior to or during transfer of patients with warfarin-associated major hemorrhage to a tertiary care center for definitive management (interventional arm) compared to patients receiving 4-factor PCC following transfer by air ambulance or ground without 4-factor PCC treatment (conventional arm). METHODS This was a retrospective chart review of patients presenting to a large academic medical center. All patients presenting to the emergency department (ED) treated with 4-factor PCC from April 1, 2014, through June 30, 2016, were identified. For this study, only transfer patients with an International Normalized Ratio (INR) > 1.5 actively treated with warfarin were included. The primary outcome was the proportion of patients with an INR ≤ 1.5 upon tertiary care hospital arrival, and the secondary efficacy outcome was difference in time to achievement of INR ≤ 1.5. Additional safety and efficacy objectives included difference in thromboembolic complications, length of stay, intensive care unit length of stay, and inpatient mortality between groups. RESULTS Of the 72 included patients, a higher proportion of patients in the interventional group had an INR ≤ 1.5 on ED arrival (proportion difference = 0.82, 95% confidence interval = 0.64-0.92, p < 0.0001) and significantly reduced time to observed INR ≤ 1.5 (181 minutes vs. 541 minutes, p = 0.001). No differences were observed in thromboembolic complications or patient-centered outcomes with the exception of mortality, which was significantly higher in patients in the interventional group. This group was also observed to have lower Glasgow Coma Scale score and higher intubation rates prior to transfer and treatment. CONCLUSIONS Dispatch of an air ambulance carrying 4-factor PCC with administration prior to transfer is feasible and leads to more rapid improvement in INR among patients with warfarin-associated major hemorrhage.

Inadvertent poisoning of seven teenagers with monosodium methanearsonate

Introduction. Monosodium methanearsonate (MSMA) is an organo-arsenic containing herbicide. There is scant information available concerning the toxicity of this chemical in humans. Case Report. Seven male teenagers, 15–18 years of age, inadvertently used a MSMA herbicide as cooking oil to fry fish. All had early gastrointestinal (GI) symptoms. Whole blood arsenic concentrations ranged from 348 to 613 μg/L and initial urine levels ranged from 81 400 to 226 300 μg-arsenic/g-creatinine. They were all treated with dimercaprol for 1 day and succimer for 19 days. They were followed for 15-months and had no evidence of any serious toxicity. Conclusion. MSMA produces early GI symptoms and very high levels of arsenic in blood and urine, but no evidence of long-term toxicity.