Shaun D. Carstairs

Sudden cardiac death associated with methylone use.

AbstractThe rise in popularity of “bath salts” as safe alternatives to MDMA (3,4-methylenedioxymethamphetamine), methamphetamine, and other illicit substances has resulted in increased scrutiny of the contents and toxicology associated with these products. We report a case of sudden death related to the synthetic cathinone methylone (3,4-methylenedioxy-N-methylcathinonmethylone) in a previously healthy 19-year-old man. Although several fatal case reports have been published involving methylone and other synthetic cathinones, this is the first reported case of sudden cardiac death associated with methylone use. Although lack of published data prevented a comparison of blood methylone concentrations between our case and existing reports, the amount of methylone we detected postmortem (0.07 mg/dL) is below those reported in MDMA-related fatalities. Our report suggests that methylone toxicity has been greatly underestimated by users of this synthetic cathinone.

Ondansetron Compared With Doxylamine and Pyridoxine for Treatment of Nausea in Pregnancy: A Randomized Controlled Trial

OBJECTIVE: To evaluate whether ondansetron or the combination of doxylamine and pyridoxine was superior for the treatment of nausea and vomiting of pregnancy. METHODS: This was a double-blind, randomized, controlled trial in which women with nausea and vomiting of pregnancy were assigned to 4 mg of ondansetron plus a placebo tablet or 25 mg pyridoxine plus 12.5 mg of doxylamine for 5 days. The primary outcome was an improvement in nausea as reported on a 100-mm visual analog scale (VAS). Secondary outcomes were a reduction in vomiting on the VAS and the proportion of patients reporting sedation or constipation while using either study regimen. RESULTS: Thirty-six women (18 in each group) were randomized to either ondansetron or pyridoxine and doxylamine, of whom 13 (72%) and 17 (94%) completed follow-up, respectively. There were no differences among the groups with regard to demographic characteristics or baseline nausea. Patients randomized to ondansetron were more likely to have an improvement in their baseline nausea as compared with those using pyridoxine and doxylamine over the course of 5 days of treatment (median VAS score decreased 51 mm [interquartile range 37–64] compared with 20 mm [8–51]; P=.019). Furthermore, women using ondansetron reported less vomiting (median VAS decreased 41 [interquartile range 17–57] compared with 17 [−4 to 38]; P=.049). There was no significant difference between the groups regarding sedation or constipation. CONCLUSION: Our investigation showed ondansetron to be superior to the combination of pyridoxine and doxylamine in the treatment of nausea and emesis in pregnancy. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01668069. LEVEL OF EVIDENCE: I

Prolonged Coma in a Child Due to Hashish Ingestion with Quantitation of THC Metabolites in Urine

BACKGROUND Cannabinoid-containing substances are commonly abused worldwide. Significant toxicity from these substances is uncommon in adults but can result in significant symptoms in children; these symptoms are usually short-lived. OBJECTIVES To report a case of prolonged mental status alteration of more than 2 days in a child who ingested hashish. CASE REPORT A 14-month-old child presented comatose to a pediatric emergency department after ingestion of hashish; she did not regain consciousness for more than 48 h. Quantitative testing of the childs urine for a tetrahydrocannabinol metabolite revealed a markedly elevated level, the decline of which coincided with the childs clinical improvement. CONCLUSIONS Significant ingestion of cannabinoid-containing substances is capable of causing prolonged symptoms (including coma) in children.

Peyote and mescaline exposures: a 12-year review of a statewide poison center database

Background. Peyote, a cactus containing the hallucinogen mescaline, has been used by Native Americans for thousands of years. Illicit use is also known to occur, but reports in the medical literature consist only of isolated case reports. Objectives. We sought to identify characteristics of patients with reported exposure to peyote or mescaline. Methods. We performed a retrospective review of the California Poison Control System database for the years 1997–2008 for all cases of single-substance human exposure using the search terms “peyote” and “mescaline.” Results. There were a total of 31 single-substance exposures to peyote or mescaline. Thirty (97%) exposures were intentional; 30 (97%) exposures were through the oral route, whereas one patient (3%) insufflated mescaline powder. Five patients (16%) were managed at home, whereas the remainder patients were managed in a healthcare facility. Commonly reported effects included hallucinations, tachycardia, agitation, and mydriasis. Vomiting was reported in only one case. Conclusions. Although uncommonly encountered, use of peyote and mescaline was associated with clinically significant effects requiring treatment in a substantial number of patients. Clinical effects were usually mild or moderate, and life-threatening toxicity was not reported in this case series.

HERLYN WERNER WUNDERLICH SYNDROME: AN UNUSUAL PRESENTATION OF ACUTE VAGINAL PAIN

BACKGROUND Herlyn Werner Wunderlich Syndrome (HWWS) is a congenital abnormality of the Müllerian duct system resulting in uterovaginal duplication, obstructive hemivagina, and ipsilateral renal agenesis. It typically presents shortly after menarche with gradual onset of progressive pelvic pain. CASE REPORT We report a case of a 19-year-old female who presented to the Emergency Department with sudden onset of severe vaginal pain that was determined to be due to hematocolpos; imaging confirmed the diagnosis of HWWS. CONCLUSIONS To the best of our knowledge abrupt onset of vaginal pain due to HWWS has not been reported previously. We present this case to increase awareness among emergency physicians of this rare and interesting entity.

Ondansetron Use in Pregnancy and Birth Defects: A Systematic Review.

OBJECTIVE: To examine the risk of birth defects in children born to women who used ondansetron early in pregnancy for nausea and vomiting of pregnancy or hyperemesis gravidarum. DATA SOURCES: PubMed, EMBASE, Cochrane, Scopus, Web of Science, Journals@Ovid Fulltext, ClinicalTrials.gov, and Google Scholar databases. METHODS OF STUDY SELECTION: Studies were included for review if they were written in English, included a comparison population of patients not exposed to ondansetron, and reported human data, original research, exposure to ondansetron during the first trimester, and structural birth defects as an outcome. TABULATION, INTEGRATION, AND RESULTS: A total of 423 records were identified. After accounting for duplicate records and including only relevant articles, a total of eight records met criteria for review. Data from the various studies were conflicting: whereas the three largest studies showed no increased risk of birth defects as a whole (36 malformations, 1,233 exposed compared with 141 malformations and 4,932 unexposed; 58/1,248 exposed compared with 31,357/895,770 unexposed; and 38/1,349 exposed compared with 43,620/1,500,085 unexposed; with odds ratios [ORs] of 1.12 (95% confidence interval [CI] 0.69–1.82), 1.3 [95% CI 1.0–1.7], and 0.95 [95% CI 0.72–1.26], respectively), two of these studies demonstrated a slightly increased risk of cardiac defects specifically (OR 2.0 [95% CI 1.3–3.1] and 1.62 [95% CI 1.04–2.14]), a finding that was not replicated in other studies. The most consistent association (if any) appears to be a small increase in the incidence of cardiac abnormalities, the bulk of which are septal defects. CONCLUSION: The overall risk of birth defects associated with ondansetron exposure appears to be low. There may be a small increase in the incidence of cardiac abnormalities in ondansetron-exposed neonates. Therefore, ondansetron use for nausea and vomiting of pregnancy should be reserved for those women whose symptoms have not been adequately controlled by other methods.

Recurrent Seizure Activity in a Child After Acute Vilazodone Ingestion

or II view. In my opinion, in the ED, if DL fails to achieve an adequate intubating view of the airway, it should be immediately abandoned and video laryngoscopy should be performed. With regard to the use of stylets during the study period, in all of our ED intubations, whether performed by DL or by VL, a stylet is used to control the tracheal tube. Again, in this high-risk patient population, there is no justification not to use a stylet to better control and direct the tracheal tube. In terms of external laryngeal manipulation, I believe it is a valuable technique to improve glottic exposure, but this information was not captured on our airway data form, so I cannot report on its frequency of use.

The spice of life: An analysis of nutmeg exposures in California

Background. Nutmeg is widely used as a household spice. Numerous citations in the medical literature report its abuse as a psychoactive agent, primarily for its purported hallucinogenic effects that are thought to be due to the compound myristicin; these are primarily limited to case reports. Methods. We performed a retrospective review of the California Poison Control System database for the years 1997–2008 for all cases of single-substance human exposure to nutmeg. Results. There were a total of 119 single-substance exposures to nutmeg. Eighty-six (72.3%) exposures were intentional. Patients intentionally abusing nutmeg were more likely to be between the ages of 13 and 20 than those with unintentional exposure to the spice (80.2% vs. 9.1%, p < 0.05). Abusers were significantly more likely to require medical evaluation than nonabusers (61.6% vs. 33.3%, p < 0.05). Patients who abused nutmeg were significantly more likely (p < 0.05) to experience tachycardia and agitation than those whose exposure was unintentional. No major effects and no deaths were reported to occur in either group. Conclusions. Although nutmeg exposure is uncommonly encountered, clinical effects from ingestion can be significant and can require medical intervention. While clinically significant effects were common, life-threatening toxicity and death did not occur in this series.

Contribution of serum ethanol concentration to the osmol gap: a prospective volunteer study

Background. The contribution of ethanol ([EtOH]) to the osmol gap (OG) is commonly described by the formula [EtOH (mg/dL)]/k, where k is assumed to be 4.6 (one-tenth of its molecular weight) if ethanol behaves ideally in solution. However, several studies on convenience samples of patients suggest that ethanol does not behave ideally and that k may be significantly different from this ideal constant. Objectives. To determine prospectively the relationship between serum ethanol concentration and total serum osmolality in a group of healthy volunteers. Methods. Experimental subjects ingested 20 mL of 100% ethanol diluted in sugar-free soda at a rate of one drink every 10 min, up to a maximum of seven drinks. Control subjects ingested 20 mL of water diluted in sugar-free soda at the same rate. Blood samples were obtained at baseline and then at every 20 min for 180 min to measure serum [EtOH] concentration, electrolytes, glucose, and osmolality (via freezing-point depression). The OG was calculated by subtracting predicted osmolality from measured osmolality. The OG was then divided by [EtOH] to determine the coefficient of ethanols contribution to total serum osmolality. Results. A total of 10 volunteers (five men and five women; mean age, 38.8 years, and range, 28–49 years) participated in and completed the study. Eight (four male and four female) were in the experimental group, and two (one male and one female) were in the control group. Mean peak [EtOH] was 229 mg/dL (median, 223.5 mg/dL; IQR, 171–273 mg/dL) and a linear relationship between [EtOH] and OG (Pearson coefficient of 0.98) was found. Using covariate correction for each subjects baseline OG, k was calculated to be 4.25 (95% CI, 4.13–4.38) averaged over all participants. Conclusions. In this volunteer study, the coefficient describing the contribution of ethanol to serum osmolality (k) was found to be 4.25. This indicates that ethanol contributes more to total serum osmolality than would be predicted for an ideal solute.

Ingestion of Lantana camara Is Not Associated With Significant Effects in Children

OBJECTIVE: We sought to identify characteristics of children with reported ingestion of Lantana camara. METHODS: We reviewed the California Poison Control System database for all reported pediatric ingestions of L camara for the years 1997–2008. Data collected included age, gender, clinical effects, duration of effects, medical interventions, and outcomes. RESULTS: There were a total of 641 patients; patient ages ranged from 1 to 16 years, with a mean of 2.5 years. Reported effects included vomiting (n = 30), abdominal pain (n = 8), agitation (n = 6), diarrhea (n = 6), throat/mouth irritation (n = 5), tachycardia (n = 4), drowsiness (n = 3), nausea (n = 2), and mydriasis (n = 1). There was no difference in frequency of symptoms between patients who ingested ripe (15.5% [95% confidence interval: 9.1%–21.8%]) versus unripe (6.0% [95% confidence interval: 0.9%–11.1%]) berries or between patients who ingested berries (10.5% [95% confidence interval: 7.3%–13.8%]) versus other plant parts (7.1% [95% confidence interval: 4.0%–10.3%]). Fifty-one patients (8%) were treated in a health care facility and 2 (0.3%) were admitted. No significant effects and no deaths were recorded. CONCLUSIONS: Ingestion of L camara (including unripe berries) was not associated with significant toxicity; patients who ingested unripe berries did not exhibit more-frequent or more-severe symptoms than did patients who ingested ripe berries or other plant parts. Most patients displayed no or minimal symptoms. Children with asymptomatic ingestions and those with mild symptoms can be treated at home.