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Publications in this journal

• Understanding How Data Triangulation Identifies Acute Toxicity of Novel Psychoactive Drugs.

  Authors: D M Wood, P I Dargan

  Journal of medical toxicology : official journal of the American College of Medical Toxicology.

  Over the last decade, there has been an increase in the availability and use of novel psychoactive substances (also known as "legal highs"). There is limited information available on the potentialOver the last decade, there has been an increase in the availability and use of novel psychoactive substances (also known as "legal highs"). There is limited information available on the potential acute toxicity (harms) associated with the use of these novel psychoactive substances. Gold standard evidence, such as animal studies or human clinical trials, is rarely available to users or healthcare professionals. However, it is possible to use triangulation of data on the acute toxicity from multiple sources to describe the overall pattern of toxicity associated with a novel psychoactive substance. In this review, we will describe these potential data sources, which include self-reported toxicity on internet discussion fora, data from sub-population user surveys, data from regional and national poisons information services and published case reports and case series. We will then describe how pattern of acute toxicity associated with the use of the cathinone mephedrone (4-methylmethcathinone) was established using triangulation of these different data sources.

• Recreational Drug Use in the Asia Pacific Region: Improvement in Our Understanding of the Problem Through the UNODC Programmes.

  Authors: P I Dargan, D M Wood

  Journal of medical toxicology : official journal of the American College of Medical Toxicology.

  Until recently, there were limited data available on the epidemiology of recreational drug use in the Asia Pacific region. However, in the last few years, a number of United Nations Office on DrugsUntil recently, there were limited data available on the epidemiology of recreational drug use in the Asia Pacific region. However, in the last few years, a number of United Nations Office on Drugs and Crime (UNODC) programmes have improved data collection networks, particularly in East and Southeast Asia. There are still significant data gaps from some countries, including India and China, and data reported from some countries in the region are based on expert estimates on recreational drug use rather than formally collected data. However, the availability of improved epidemiological data has enabled many countries in the region, both individually and through regional UNODC programmes, to start to understand the issues that need to be addressed. We will summarise in this mini-review the data available within the UNODC World Drug Report and from the other UNODC programmes in the region on the production and use of recreational drugs in the Asia Pacific region.

• The Skill of Writing.

  Authors: Bryan S Judge

  Journal of medical toxicology : official journal of the American College of Medical Toxicology.

• Heavy Metal Contaminants in Yerberia Shop Products.

  Authors: Michael Levine, Jason Mihalic, Anne-Michelle Ruha, Robert N E French, Daniel E Brooks

  Journal of medical toxicology : official journal of the American College of Medical Toxicology.

  Complementary and alternative medications, including the use of herbal medications, have become quite popular in the USA. Yerberias are found throughout the southwest and specialize in sellingComplementary and alternative medications, including the use of herbal medications, have become quite popular in the USA. Yerberias are found throughout the southwest and specialize in selling Hispanic herbal products. The products sold in these stores are not regulated by any governmental agency. Previous reports have found Ayurvedic medications contain high levels of lead, mercury, and arsenic. The primary purpose of this study is to examine the prevalence of heavy metal contaminants sold at Yerberia stores in the southwest. Yerberias in the Phoenix, Arizona area were identified via search of an on-line search engine using the words "Yerberia Phoenix." Every second store was selected, and products were purchased using a standard script. The products were subsequently analyzed for mercury, lead, and arsenic. The main outcome is the prevalence of heavy metal content in over-the-counter "cold" medications purchased at a Yerberia. Twenty-two samples were purchased. One product contained pure camphor (2-camphone) and was subsequently not further analyzed. Of the 21 samples analyzed, lead was found in 4/21 (19.4 %). Arsenic and mercury were in 1/21 (4.8 %) each. Because two samples contained two heavy metals, the total prevalence of heavy metals was 4/21 (19.4). Heavy metal contaminants are commonly encountered in over-the-counter herbal "cold" medications purchased at Yerberias in the southwest.

• Clinical Course of Bark Scorpion Envenomation Managed Without Antivenom.

  Authors: Ayrn O'Connor, Anne-Michelle Ruha

  Journal of medical toxicology : official journal of the American College of Medical Toxicology.

  Bark scorpion envenomation is potentially life threatening in children and traditionally treated with antivenom (AV). We sought to describe the clinical course, management, complications and outcomeBark scorpion envenomation is potentially life threatening in children and traditionally treated with antivenom (AV). We sought to describe the clinical course, management, complications and outcome of children with severe scorpion envenomation treated with supportive care during a period when AV was unavailable. A retrospective chart review was performed, all children presenting to a referral hospital between September 1, 2004 and July 31, 2006 with severe scorpion envenomation not receiving AV, were included. A standardized data abstraction form was used to record time of symptom onset, time to healthcare facility (HCF), clinical findings, treatment, complications, and length of stay. Eighty-eight patients were included with mean age of 3.7 years (0.33-12). Mean time to symptom onset was 20 min (0-130) and mean time to HCF was 79 min (10-240). Incidence of clinical manifestations include: neuromuscular agitation, 100 %; opsoclonus, 97 %; hypersalivation, 81 %; tachycardia, 82 %; hypertension, 49 %; vomiting, 38 %; fever, 28 %; respiratory distress, 33 %; and hypoxia, 18 %. Complications included rhabdomyolysis in 18 (20 %) and aspiration in 12 (13 %) patients. Intubation was required in 24 % of patients. The most frequently used agents to control symptoms were benzodiazepines (98 %) followed by opioids (69 %). Intravenous fluids were given to 84 %. Mean length of stay was 29 h (range, 6-73 h). There were no deaths. In addition to the classic findings of neuromuscular hyperactivity, opsoclonus, and hypersalivation, a high incidence of hyperadrenergic findings and respiratory compromise are noted in this series. A significant number of patients required mechanical ventilation. Benzodiazpines and opioids were the most common medications used to control symptoms.

• Stimulant Methamphetamine and Dextromethorphan Use Among Thai Adolescents: Implications for Health of Women and Children.

  Authors: Chulathida Chomchai, Boonying Manaboriboon

  Journal of medical toxicology : official journal of the American College of Medical Toxicology.

  For over a decade, amphetamine-type stimulants have made their way into the adolescent culture of Thailand. Coupled with the more recent emergence of the legal, over-the-counter cough medicineFor over a decade, amphetamine-type stimulants have made their way into the adolescent culture of Thailand. Coupled with the more recent emergence of the legal, over-the-counter cough medicine dextromethorphan (DM), they represent the most commonly abused substances among Thai youths today. Methamphetamine is the second most popular drug of abuse in Thailand, the first being cannabis. It is available in the crystalline version, ICE, and the less pure methamphetamine tablets. The tablets are frequently crushed and smoked. Its use has gained enormous popularity among teenagers and young adults, including women of child-bearing age. As such, it has become the most common drug being detected in the urine of peripartum women, resulting in peripartum and postpartum complications for both mother and child. DM is a newer drug which has gained popularity among middle school and high school students due to its easy availability as a single product over the counter. It is usually taken with soft drinks at parties and gathering. It is metabolized by CYP4502D6 to dextrorphan, the substance responsible for the feeling of euphoria. Consequently, those who are poor metabolizers often experience the "negative" effects associated with the drug. The recreational use of methamphetamine and dextromethorphan in teenagers and young adults in Thailand is a serious problem. Recognizing not only the toxicological but also the emotional and psychosocial impacts of these drugs on Thai youth is an integral part of approaching the problem.

• The Role of the Medical Toxicologist in Organ Transplantation.

  Authors: Lewis R Goldfrank, Stephen P Wall, Rama B Rao

  Journal of medical toxicology : official journal of the American College of Medical Toxicology.

• A Descriptive Comparison of Alcohol-Related Presentations at a Large Urban Hospital Center from 1902 to 2009.

  Authors: Bradley D Shy, Robert S Hoffman

  Journal of medical toxicology : official journal of the American College of Medical Toxicology.

  Although alcohol use has long been a significant cause of hospital presentations, little is published regarding the long-term demographic changes that have occurred at a single hospital site. ToAlthough alcohol use has long been a significant cause of hospital presentations, little is published regarding the long-term demographic changes that have occurred at a single hospital site. To address this deficit, we prospectively studied all acute alcohol-related presentations to Bellevue Hospital Center (New York, NY) and compared this contemporary data set with one from the same institution from 1902 to 1935. We prospectively identified all patients presenting to the emergency department because of acute alcohol use over an 8-week period in 2009. We described the basic attributes of patients presenting currently because of alcohol and compared these data to those previously described between 1902 and 1935. We also compared our census data with contemporaneous data from all patients presenting to this hospital site. During the study period, 560 patients presented because of acute alcohol use which extrapolated to an estimated 3,800 patients over the calendar year. This compares to 7,600 presentations recorded annually early in the twentieth century. Twelve percent of patients in 2009 were female as compared to 18 % of patients between 1934 and 1935. Patients with alcohol-related presentations in 2009 were more likely to be admitted than contemporaneous patients without an alcohol-related presentation (30 vs. 19 % admitted; p < 0.001). Since first measured 110 years ago at one large New York City hospital, alcohol-related presentations remain common representing 5 % of all emergency department visits. This demonstrates alcoholism's continuing toll on society's limited medical resources and on public health as a whole.

• Articles You Might Have Missed.

  Authors: Christine M Murphy

  Journal of medical toxicology : official journal of the American College of Medical Toxicology.

• Writing an Effective Review Article.

  Authors: Christine M Murphy

  Journal of medical toxicology : official journal of the American College of Medical Toxicology.

• Acute and Chronic Toxicity Pattern in Ketamine Abusers in Hong Kong.

  Authors: Chan Yiu-Cheung

  Journal of medical toxicology : official journal of the American College of Medical Toxicology.

  Ketamine has been the commonest abusive substance used by Hong Kong teenager since 2005. It is also the fourth commonest poison encountered in Hong Kong Poison Information Centre (HKPIC) poisoningKetamine has been the commonest abusive substance used by Hong Kong teenager since 2005. It is also the fourth commonest poison encountered in Hong Kong Poison Information Centre (HKPIC) poisoning data in 2010. From June 2008 to July 2011, HKPIC managed 188 and 96 cases of acute and chronic ketamine poisoning, respectively, which reflect its acute and chronic toxicity pattern. Demographically, there is a male predominance, and the majority is between the ages of 10-39. For the acute cases, 48 % presented with neurological features such as confusion, drowsiness, or transient loss of consciousness which usually subside with supportive care in a few hours. For the chronic cases, 92 % of them presented with features of ketamine cystitis while about 66 % presented with chronic abdominal pain. The current understanding of ketamine cystitis and chronic abdominal pain will be reviewed. Management is primarily symptomatic measures and most importantly abstinence from ketamine use.

• Acute Electrocardiographic ST Segment Elevation May Predict Hypotension in a Swine Model of Severe Cyanide Toxicity.

  Authors: Tylan A Muncy, Vikhyat S Bebarta, Shawn M Varney, Rebecca Pitotti, Susan Boudreau

  Journal of medical toxicology : official journal of the American College of Medical Toxicology.

  Cyanide causes severe cardiac toxicity resulting in tachycardia, hypotension, and cardiac arrest; however, the clinical diagnosis can be difficult to make. A clinical finding that may precede orCyanide causes severe cardiac toxicity resulting in tachycardia, hypotension, and cardiac arrest; however, the clinical diagnosis can be difficult to make. A clinical finding that may precede or predict cyanide-induced hypotension may be a trigger to provide treatment earlier and improve outcomes in cyanide toxicity. Our primary objective was to determine if there is a clinically significant change in ST segment deviation measured on ECG during intravenous cyanide infusion that may predict cyanide-induced hypotension. As part of a larger study comparing antidotes for cyanide-induced shock, 30 swine were anesthetized and monitored and then intoxicated with a continuous cyanide infusion until severe hypotension (50 % of baseline mean arterial pressure) occurred. ECGs were obtained at baseline, every 5 min during infusion, and at the development of hypotension. Repeated measures of analysis of variance were used to determine significance. The mean weight for the 30 swine at baseline was 48 kg (range 45-52), pulse rate 86 beats/min (range 55-121), and systolic blood pressure 109 mmHg (range 90-121). The mean time to hypotension was 31 min (range 16-39). The mean amount of cyanide infused was 5 mg/kg (range 2.5-6.3 mg/kg). All animals (30/30) had ECG changes in repolarization or depolarization during cyanide infusion. Significant rhythm, repolarization, and conduction changes from baseline were observed prior to severe hypotension (p < 0.05). Normal sinus rhythm and sinus tachycardia were the most common rhythms preceding hypotension. We observed ST segment elevation in leads V3, V4, III, and aVF and ST segment depression in leads aVL and aVR. The most pronounced ST segment elevation was observed in leads V3 and V4. We also detected significant changes with increased pulse rate, prolonged PR interval, and shortened QTc interval. Other significant changes were increased T axis and reduced QRS axis. We detected ST segment deviations occurring just before the onset of cyanide-induced hypotension in our swine model. Leads V3 and V4 had the most pronounced with ST elevation, but we also detected electrocardiographic ST elevation inferiorly. Shortening of the QTc and lengthening of the PR interval were also detected before hypotension.

• Psychosis from a Bath Salt Product Containing Flephedrone and MDPV with Serum, Urine, and Product Quantification.

  Authors: Stephen L Thornton, Roy R Gerona, Christian A Tomaszewski

  Journal of medical toxicology : official journal of the American College of Medical Toxicology.

  INTRODUCTION: The use of designer drugs commonly marketed as bath salts or plant food has risen dramatically in recent years. Several different synthetic cathinones have been indentified in theseINTRODUCTION: The use of designer drugs commonly marketed as bath salts or plant food has risen dramatically in recent years. Several different synthetic cathinones have been indentified in these products, including mephedrone, 3,4-methylenedioxypyrovalerone (MDPV), and 4-fluoromethcathinone (flephedrone). We report a case of bath salt intoxication with quantitative MDPV and flephedrone levels in a patient's serum and urine, and from the bath salt product. CASE REPORT: A 23-year-old male with a prior psychiatric history arrived via EMS for bizarre behavior, suicidality, and hallucinations after reportedly insufflating a bath salt. He was found to have MDPV levels of 186 and 136 ng/mL in his serum and urine, respectively, and flephedrone levels of 346 and 257 ng/mL in the serum and urine, respectively. The white powder in question was found to contain 143 μg MDPV and 142 μg flephedrone per milligram powder. His psychosis and agitation resolved with lorazepam, droperidol, and observation in the emergency department. DISCUSSION: Agitation, psychosis, movement disorders, tachycardia, and hypertension have all been attributed to the use of MDPV; there are no prior reports detailing clinical experience with flephedrone. Considering that our patient's serum flephedrone levels were twofold higher than his MDPV level, it is likely flephedrone contributed to his clinical toxicity. This case suggests the possibility that fluorinated cathinones, such as flephedrone, may have altered metabolism and/or elimination which may affect their course of clinical toxicity. This case highlights the evolving composition of synthetic cathinones found in bath salt products.

• Toxico-Surveillance of Infant and Toddler Poisonings in the United States.

  Authors: Yaron Finkelstein, Janine R Hutson, Paul M Wax, Jeffrey Brent

  Journal of medical toxicology : official journal of the American College of Medical Toxicology.

  Infant and toddler poisonings are important to capture and may be challenging to manage. We aim to describe the Toxicology Investigators Consortium (ToxIC) Case Registry as a tool forInfant and toddler poisonings are important to capture and may be challenging to manage. We aim to describe the Toxicology Investigators Consortium (ToxIC) Case Registry as a tool for toxico-surveillance of this problem in the United States. Using the ToxIC Case Registry database of the American College of Medical Toxicology, we identified infant and toddler poisonings over a 15-month period between April 1, 2010 and June 30, 2011 reported to the 31 Registry sites. Of 6,810 poisoning cases reported to the ToxIC registry, 248 (3.6 %) involved children younger than 2 years (51 % males). Fifty-four percent were hospital inpatients, 42 % were in the Emergency Department and 4 % were outpatients. Sixty-three percent were symptomatic. The most common ingested compounds were highly toxic-cardiac drugs (16 %), psychotropics (15 %), recreational drugs, alcohols, and controlled narcotic drugs (13 %), analgesics (9 %), and cleaning compounds (7 %). Fourteen percent of cases involved multiple agents. The ToxIC registry is a potentially useful toxico-surveillance tool to identify and trend clinically significant poisonings in young children, and potentially other populations. These data could be used to target specific preventive interventions.

• A Comparison of the Prevalence of Lead-Contaminated Imported Chinese Ceramic Dinnerware Purchased Inside Versus Outside Philadelphia's Chinatown.

  Authors: Thomas Gilmore, Gerald F O'Malley, Wayne Bond Lau, David R Vann, Adam Bromberg, Aaron Martin, Andrea Gibbons, Evan Rimmer

  Journal of medical toxicology : official journal of the American College of Medical Toxicology.

  Lead-contaminated ceramics can be a clinically significant source of lead poisoning, with the potential to cause illness in children and adults; one death in a child has been described. WeLead-contaminated ceramics can be a clinically significant source of lead poisoning, with the potential to cause illness in children and adults; one death in a child has been described. We hypothesized that the prevalence of lead-contaminated ceramics would be higher within Chinatown versus outside of Chinatown. The study was a prospective observational cross-sectional study. Two areas were defined geographically as being within and outside of Philadelphia's Chinatown, and a predefined number of items were purchased in each area. Each item was screened for lead utilizing a colorimetric testing swab. Positive items were leached for lead using the ASTM C738-94 protocol for lead level quantification. The primary outcome was the prevalence of ceramics not compliant with the FDA standard for leachable lead within and outside of Philadelphia's Chinatown. A total of 132 items were purchased, 46 outside of and 86 within Chinatown. More lead-positive items originated within Chinatown than outside of Chinatown [five positive items, 5.8 % prevalence within Chinatown (95 % confidence interval, CI, 2.5-12.9 %), and zero positive, 0 % prevalence outside of Chinatown (95 % CI 0-7.5 %)]. However, this difference was not found to be statistically significant (P = 0.1624). The leachable lead-positive items were up to 40-fold the acceptable FDA levels. Testing a larger number of items may demonstrate a significant source of lead exposure.

• Influence of Drug Use on Morbidity and Mortality in Heatstroke.

  Authors: Michael Levine, Frank Lovecchio, Anne-Michelle Ruha, Gregory Chu, Pedro Roque

  Journal of medical toxicology : official journal of the American College of Medical Toxicology.

  Numerous medications and illicit drugs can predispose an individual to heat illness, primarily by altering thermoregulation by either increasing endogenous heat production or impairing heatNumerous medications and illicit drugs can predispose an individual to heat illness, primarily by altering thermoregulation by either increasing endogenous heat production or impairing heat dissipation. This study sought to determine if use of such drugs was associated with more severe illness in patients presenting with heatstroke. A case control study was conducted on adult patients (age, ≥14 years) admitted to an intensive care unit with an admitting diagnosis of heatstroke at two academic teaching hospitals in Phoenix, AZ, between 31 August 2005 through 31 July 2010. Subjects were classified as "users" if they admitted to taking a drug on a pre-defined list of drugs associated with abnormal thermal homeostasis, or if a urine test for drugs of abuse revealed the presence of an amphetamine or cocaine. Similarly, subjects who did not take such drugs were considered "non-users." Seventy-eight patients were identified, with complete medication histories available for 74 of 78 subjects. The overall prevalence of drug utilization was 41.9 % (31 of 74). The median length of stay was 3.0 days for the non-users compared with 9.0 days for "users." There was no difference between users and non-users with regard to mortality. Drugs that impair thermoregulation are frequently encountered in patients admitted for heatstroke. Patients taking such drugs may experience increased morbidity over those patients not taking such drugs.

• Toxicology and "One Health": Opportunities for Multidisciplinary Collaborations.

  Authors: Wilson K Rumbeiha

  Journal of medical toxicology : official journal of the American College of Medical Toxicology.

• Nasopharyngeal Necrosis After Chronic Opioid (Oxycodone/Acetaminophen) Insufflation.

  Authors: Christopher D Rosenbaum, Katherine L Boyle, Edward W Boyer

  Journal of medical toxicology : official journal of the American College of Medical Toxicology.

  Nasopharyngeal necrosis resulting from narcotic insufflation is a recognized phenomenon, but cocaine use is more commonly associated with this pathology than opioid abuse. Physical exam findingsNasopharyngeal necrosis resulting from narcotic insufflation is a recognized phenomenon, but cocaine use is more commonly associated with this pathology than opioid abuse. Physical exam findings associated with severe tissue destruction are not routinely seen on physical examination or available in the medical literature. We present a case of chronic oxycodone/acetaminophen insufflation and images of a defect in the soft palate.

• Unintentional Chronic Acetaminophen Poisoning During Pregnancy Resulting in Liver Transplantation.

  Authors: Stephen L Thornton, Alicia B Minns

  Journal of medical toxicology : official journal of the American College of Medical Toxicology.

  INTRODUCTION: Acetaminophen (APAP) is a widely used medication in pregnancy and is considered safe. Unfortunately, APAP is also among the most commonly reported agents implicated in overdoses duringINTRODUCTION: Acetaminophen (APAP) is a widely used medication in pregnancy and is considered safe. Unfortunately, APAP is also among the most commonly reported agents implicated in overdoses during pregnancy. We present a unique case of a pregnant patient with fulminant hepatic failure resulting in a liver transplant from repeated supratherapeutic ingestions of APAP. CASE REPORT: A 22 year pregnant female presented with abdominal pain and hepatotoxicity after taking supratherapeutic amounts of APAP to treat dental pain. The patient denied intentional or acute ingestion of APAP but did admit to taking approximately 8-9 grams of APAP per day for 10-14 days for dental pain. Other cause of hepatotoxicity, including acute fatty liver of pregnancy, were evaluated for and ruled out. She developed fulminant hepatic failure and required liver transplantation which was successful. The pregnancy remained viable through the operation but intrauterine fetal demise occurred 2 weeks later. An MRI of the fetus showed extensive peri-cerebral and intraventricular hemorrhage with extensive periventricular leukomalacia. DISCUSSION: The degree of morbidity from repeated supratherapeutic ingestions of APAP seen in this case is rare and poorly described in a pregnant patient. There are no prior reports describing the need for liver transplant after repeated supratherapeutic ingestions of APAP during pregnancy. Along with the typical cause of hepatotoxicy several unique pregnancy-related causes also had to be evaluated for. This case highlights the significant morbidity that can occur with even unintentional APAP toxicity and the need to educate patients, especially pregnant patients, of the risk of excessive APAP use.

• Response to the Letter by Dr. Farzad Gheshlaghi.

  Authors: Sudheera Jayasinghe

  Journal of medical toxicology : official journal of the American College of Medical Toxicology.

• Further Study is Needed to Assess Ototoxicity from Organophosphates and Paraquat.

  Authors: Farzad Gheshlaghi

  Journal of medical toxicology : official journal of the American College of Medical Toxicology.

• Aluminium Phosphide Poisoning and Oxidative Stress : Serum Biomarker Assessment.

  Authors: Hamid Kariman, Kamran Heydari, Mohammad Fakhri, Ali Shahrami, Ali Arhami Dolatabadi, Hossein Ali Mohammadi, Morteza Gharibi

  Journal of medical toxicology : official journal of the American College of Medical Toxicology.

  According to previous animal studies, aluminium phosphides (AlPs) may induce oxidative stress leading to generation of free radicals and alteration in antioxidant defense system. This study wasAccording to previous animal studies, aluminium phosphides (AlPs) may induce oxidative stress leading to generation of free radicals and alteration in antioxidant defense system. This study was conducted to evaluate the existence and degree of oxidative stress in patients with acute AlP ingestion. A total of 44 acute AlP ingested patients as well as 44 age- and sex-matched controls were included. All patients had acute poisoning symptoms with AlP at the time of presentation and had blood samples analyzed for lipid peroxidation, total antioxidant capacity and total thiol. Our findings showed that there is a significant increase in lipid peroxidation in AlP ingested group along with a reduction in total antioxidant capacity and total thiols groups. These clinical data confirm previous experimental models that showed AlP exposure might significantly augment lipoperoxidative damage with simultaneous alterations in the antioxidant defense system. Hence, our findings might justify use of antioxidants in treatment of acute AlP poisoning which needs to be clarified by additional clinical trials.

• Death Following Recreational Use of Designer Drug "Bath Salts" Containing 3,4-Methylenedioxypyrovalerone (MDPV).

  Authors: Brittany L Murray, Christine M Murphy, Michael C Beuhler

  Journal of medical toxicology : official journal of the American College of Medical Toxicology. 8(1):69-75.

  3,4-Methylenedioxypyrovalerone (MDPV) is a designer stimulant drug that has gained popularity in the USA. Although adverse effects of MDPV have been described, to our knowledge, this is the first3,4-Methylenedioxypyrovalerone (MDPV) is a designer stimulant drug that has gained popularity in the USA. Although adverse effects of MDPV have been described, to our knowledge, this is the first reported death. We report the case of a 40-year-old male who injected and snorted "bath salts" containing MDPV and subsequently became agitated, aggressive, and experienced a cardiac arrest. He was resuscitated after his initial arrest; however, he developed hyperthermia, rhabdomyolysis, coagulopathy, acidosis, anoxic brain injury, and subsequently died. This is the first case in the medical literature to report death due to isolated confirmed MDPV intoxication. The manner of death is also consistent with excited delirium syndrome.

• Fear Not the IME.

  Authors: Christine M Murphy

  Journal of medical toxicology : official journal of the American College of Medical Toxicology. 8(1):3-4.

• Clinical Experience with Intravenous Lipid Emulsion for Drug-Induced Cardiovascular Collapse.

  Authors: Ann-Jeannette Geib, Erica Liebelt, Alex F Manini

  Journal of medical toxicology : official journal of the American College of Medical Toxicology. 8(1):10-14.

  Intravenous lipid emulsion (ILE) is an emerging therapy for refractory cardiotoxicity due to lipid-soluble drugs. The purpose of this study was to assess survival to hospital discharge, effects onIntravenous lipid emulsion (ILE) is an emerging therapy for refractory cardiotoxicity due to lipid-soluble drugs. The purpose of this study was to assess survival to hospital discharge, effects on hemodynamic parameters, and adverse event occurrence for patients who were treated with ILE as part of the resuscitative effort for drug-induced cardiotoxicity. This is a multicenter retrospective chart review of inpatients at three tertiary referral medical centers receiving ILE for drug-induced cardiotoxicity between November 2007 and March 2009. Nine cases with drug-induced cardiovascular collapse, defined as cardiac arrest or refractory shock, were selected for review if patients received either bolus or infusion of ILE in any combination. No interventions were done. The main outcome measures were survival to hospital discharge, effect on hemodynamic parameters, and adverse event. Hemodynamic vital signs (heart rate, systolic blood pressure, diastolic blood pressure, calculated mean arterial pressure [MAP]) were measured before administration of ILE and up to five measurements (if available) were recorded after administration of ILE. Attribution of adverse events was determined by assignment of Naranjo adverse drug reaction (ADR) likelihood score (3) with adjudication of three medical toxicologists; disagreements were settled by majority consensus. Of nine cases identified based on inclusion criteria (three cardiac arrest, six refractory shock), five (55%) survived to hospital discharge. ILE regimens were bolus alone in five patients and bolus plus infusion in four patients. Hemodynamic trends in response to ILE demonstrated no difference in MAP immediately pre- and post-administration of ILE (p = NS). Administration of infusion (versus boluses alone) did not demonstrate a statistically significant improvement in MAP. Adverse events due to ILE therapy that were categorized as "possible" or "probable" based on Naranjo scores included lipemia, digit amputation, lung injury, renal failure, and deep venous thrombosis. ILE administered to patients with drug-induced cardiovascular collapse was associated with 55% survival but with clinically significant adverse effects. At this time, ILE should be restricted to cardiotoxicity involving cardiac arrest or refractory shock until further prospective studies can better evaluate risks and benefits of ILE therapy.

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