Publications by authors named "Alexandra Amaducci"

11 Publications

  • Page 1 of 1

The Toxicology Investigators Consortium 2020 Annual Report.

J Med Toxicol 2021 10 17;17(4):333-362. Epub 2021 Sep 17.

University of Colorado School of Medicine, 13001 E 17th Pl, Aurora, CO, 80045, USA.

The Toxicology Investigators Consortium (ToxIC) Registry was established by the American College of Medical Toxicology in 2010. The registry collects data from participating sites with the agreement that all bedside and telehealth medical toxicology consultation will be entered. This eleventh annual report summarizes the Registry's 2020 data and activity with its additional 6668 cases. Cases were identified for inclusion in this report by a query of the ToxIC database for any case entered from January 1 to December 31, 2020. Detailed data was collected from these cases and aggregated to provide information which included demographics, reason for medical toxicology evaluation, agent and agent class, clinical signs and symptoms, treatments and antidotes administered, mortality, and whether life support was withdrawn. Gender distribution included 50.6% cases in females, 48.4% in males, and 1.0% identifying as transgender. Non-opioid analgesics were the most commonly reported agent class, followed by opioid and antidepressant classes. Acetaminophen was once again the most common agent reported. There were 80 fatalities, comprising 1.2% of all registry cases. Major trends in demographics and exposure characteristics remained similar to past years' reports. Sub-analyses were conducted to describe race and ethnicity demographics and exposures in the registry, telemedicine encounters, and cases related to the COVID-19 pandemic.
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October 2021

Syndrome of Inappropriate Antidiuretic Hormone Secretion and Lead Toxicity in a Child With Sickle Cell Disease and Pica.

Cureus 2021 Aug 1;13(8):e16813. Epub 2021 Aug 1.

Division of Medical Toxicology, Department of Emergency and Hospital Medicine, Lehigh Valley Health Network/University of South Florida Morsani College of Medicine, Allentown, USA.

We describe the presentation and management of a three-year-old child with a history of pica, vitamin D deficiency, and sickle cell disease, who was admitted for pyelonephritis, and found to have elevated blood lead level (BLL) of 103.7 µg/dL, and who subsequently developed altered mental status and syndrome of inappropriate antidiuretic hormone secretion (SIADH). In consultation with Medical Toxicology, the patient was chelated with calcium disodium edetate (EDTA) and British Anti Lewisite (BAL). The patient's hyponatremia was managed with hypertonic saline infusion. The patient's encephalopathy improved throughout her hospital course, and she was discharged on hospital day 8. Following five days of EDTA and three days of BAL injections, her repeat BLL was 15.3 µg/dL. SIADH has been associated with severe lead poisoning and may be more likely to occur in high risk patients such as individuals with sickle cell anemia, particularly where medications are used that may cause iatrogenic hyponatremia.
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August 2021

Reversible Total Vision Loss Caused by Severe Metformin-associated Lactic Acidosis: A Case Report.

Clin Pract Cases Emerg Med 2021 May;5(2):206-209

Lehigh Valley Health Network, Department of Emergency and Hospital Medicine, Allentown, Pennsylvania.

Introduction: Metformin is a biguanide used to treat diabetes mellitus (DM). Metformin-associated lactic acidosis (MALA) carries a high mortality and can occur in patients with renal failure from drug bioaccumulation. Reversible vision loss is a highly unusual, rarely reported complication of MALA. We present a case of a patient whose serum metformin concentration was unusually high and associated with vision loss.

Case Report: A 60-year-old woman presented to an outside hospital emergency department with acute vision loss after being found at home confused, somnolent, and hypoglycemic, having last being seen normal two days prior. She reported vomiting and diarrhea during that time and a recently treated urinary tract infection. The visual loss resolved with continuous renal replacement therapy.

Conclusion: This novel case of a patient with Type II DM prescribed metformin and insulin who developed reversible vision loss while suffering from MALA highlights the potential for vision loss in association with MALA.
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May 2021

Influence of Pennsylvania liquor store closures during the COVID-19 pandemic on alcohol withdrawal consultations.

Am J Emerg Med 2021 Jul 31;50:156-159. Epub 2021 Jul 31.

Lehigh Valley Health Network, USF Morsani College of Medicine, Allentown, PA, United States of America.

Introduction: Alcohol withdrawal syndrome (AWS) is a serious consequence of alcohol use disorder (AUD). Due to the current COVID-19 pandemic there was a closure of Pennsylvania (PA) liquor stores on March 17, 2020.

Methods: This is a retrospective, observational study of AWS patients presenting to a tertiary care hospital. We used descriptive statistics for continuous and categorical variables and compared AWS consults placed to the medical toxicology service for six months preceding liquor store closure to those placed between March 17, 2020 and August 31, 2020. We compared this to consults placed to the medical toxicology service placed from October 1, 2019 through March 16, 2020. Charts were identified based on consults placed to the medical toxicology service, and alcohol withdrawal was determined via chart review by a medical toxicologist. This study did not require IRB approval. We evaluated Emergency Department (ED) length of stay (LOS), weekly and monthly consultation rate, rate of admission and ED recidivism, both pre- and post-liquor store closure.

Results: A total of 324 AWS consults were placed during the ten month period. 142 (43.8%) and 182 (56.2%) consults were pre- and post-liquor store closure. The number of consults was not statistically significant comparing these two time frames. There was no significant difference by patient age, gender, or race or by weekly or monthly consultation rate when comparing pre- and post-liquor store periods. The median ED LOS was 7 h (95% Confidence Interval (CI) Larson et al. (2012), Pollard et al. (2020) [5, 11]) and did not significantly differ between pre- and post-liquor store periods (p = 0.78). 92.9% of AWS patients required admission without significant difference between the pre- and post-liquor store closure periods (94.4% vs. 91.8%, p = 0.36). There was a significant increase in the number of AWS patients requiring a return ED visit (Odds Ratio 2.49; 95% CI [1.38, 4.49]) post closure.

Conclusion: There were nearly 2.5 times greater odds of ED recidivism among post-liquor store closure AWS patients compared with pre-closure AWS patients.
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July 2021

A Case Report of Widely Disseminated Tuberculosis in Immunocompetent Adult Male.

Clin Pract Cases Emerg Med 2020 Aug;4(3):375-379

Lehigh Valley Health Network/USF Morsani College of Medicine, Department of Emergency and Hospital Medicine, Allentown, Pennsylvania.

Introduction: Disseminated tuberculosis (TB) is rare, affects any organ system, and presents mainly in immunocompromised populations. Typical presentation is non-specific, posing a challenge for diagnosis.

Case Report: This case presents an immunocompetent male presenting with severe headaches with meningeal signs. Lab and lumbar puncture results suggested bacterial meningitis, yet initial cerebral spinal fluid cultures and meningitis/encephalitis polymerase chain reaction were negative. A chest radiograph (CXR) provided the only evidence suggesting TB, leading to further tests showing dissemination to the brain, spinal cord, meninges, muscle, joint, and bone.

Discussion: This case stands to acknowledge the difficulty of diagnosis in the emergency department (ED), and the need for emergency physicians to maintain a broad differential including disseminated TB as a possibility from the beginning of assessment. In this case, emergency physicians should be aware of predisposing factors of disseminated TB in patients presenting with non-specific symptoms. They should also acknowledge that TB may present atypically in patients with minimal predisposing factors, rendering the need to further investigate abnormal CXR images despite lab results inconsistent with TB.

Conclusion: While this diagnosis is easily missed, early identification in the ED can lead to optimal treatment.
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August 2020

Sex-specific Outcomes in a Substance Use Intervention Program.

Clin Ther 2020 03 9;42(3):419-426. Epub 2020 Mar 9.

University of South Florida Morsani College of Medicine, Lehigh Valley Campus, Allentown, PA, USA; Department of Emergency and Hospital Medicine, Lehigh Valley Health Network, Allentown, PA, USA.

Purpose: We performed an emergency department (ED)-based substance use screening, motivational interview-based intervention, and treatment referral program with the goal of determining sex-specific outcomes. Specifically, in this quality improvement project, we aimed to determine whether there was a difference among sexes in the type of substances used; the frequency of positive screening results for substance use disorder; agreeing to an intervention; the type of follow-up evaluation, participation, and referral; and attempts to change substance use after intervention.

Methods: We prospectively studied a convenience sample of patients at 3 hospitals in Northeastern Pennsylvania from May 2017 through February 2018. Inclusion criteria for participation in this study were age ≥18 years; ability to answer survey questions; willingness and ability (not being too ill) to participate in intervention(s); and when screened, admitting to use of alcohol, tobacco, potentially addictive prescription drugs, or street drugs. Practitioners in the ED screened patients. For those with unhealthy substance use, a brief motivational interview was performed. Participants were each given referrals and information in accordance with the particular substance used and their assessed readiness to change. Individuals who completed the intervention were contacted by telephone for follow-up. Self-reported outcomes and the frequency of successful warm hand-off referrals were assessed.

Findings: Of the 2209 individuals screened, 976 (44.2%) were male. Overall, 547 patients screened positive for at least 1 of the unhealthy substances for a prevalence of 24.8% (95% confidence interval, 22.9%-26.6%). In this population, a greater proportion of men screened positive than women (30.5% vs 20.2%, P = 0.01). Although the finding was not statistically significant, men (106 [35.6%]) were more likely than women (81 [32.5%]) to agree to an ED intervention. At telephone follow-up, men were more likely to report participating in a treatment or support program than women (32.9% vs 18.2%, P = 0.035). Frequencies of warm hand-off referrals were 11 of 106 (10.4%) for men and 2 of 81 (2.5%) for women.

Implications: Our small study found that unhealthy substance use rates were greater overall in men than women. Overall participation differences between men and women who agreed to take part in substance intervention and accepted a referral for follow-up treatment were not statistically significant. At telephone follow-up, more men reported participating in a treatment program than women. Direct referral (warm hand-off) rates to treatment programs were small in both sexes but greater in men than women.
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March 2020

Adverse Drug Events and Reactions Managed by Medical Toxicologists: an Analysis of the Toxicology Investigators Consortium (ToxIC) Registry, 2010-2016.

J Med Toxicol 2019 10 15;15(4):262-270. Epub 2019 Jul 15.

Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.

Introduction: Adverse drug events/reactions (ADE/ADRs) cost more than $30 billion annually and are among the leading causes of death in the USA. Little is known about patients treated at the bedside for ADE/ADR by medical toxicologists.

Methods: We conducted a retrospective study of ADE/ADR cases reported to the Toxicology Investigators Consortium (ToxIC) registry between January 1, 2010, and December 31, 2016. Clinical and demographic data were collected including age, sex, circumstances surrounding exposure, suspected offending substance, clinical manifestations, treatment, disposition, and outcome.

Results: Among 51,440 ToxIC cases during this time period, 673 ADE/ADR cases were reported (337 females). By age, ADE/ADRs were seen most commonly among adults age 19-65 years (442/673, 65.7% of ADE/ADR) and older adults age 65-89 years (134/673, 19.9% of ADE/ADR). 222/673 (33%) of consults for ADE/ADR were seen in the emergency department (ED); 181/673 (26.9%) were seen in the hospital ward; and 160/673 (23.8%) were seen in the intensive care unit (ICU). The most commonly reported sign for ADE/ADR was tachycardia: 51/673 (7.6%), followed by bradycardia: 49/673 (7.3%). Most commonly reported agents associated with ADE/ADR were as follows: 97/673 (14.4%) due to cardiovascular medications; 76/673 (11.3%) due to antipsychotic medications; and 61/673 (9.1%) due to antidepressants. 429/673 (63.7%) of ADE/ADR were reported as due to a single agent, and 212/673 (31.5%) were reported as due to multiple agents.

Conclusions: 4.2% of cases managed at the bedside by a consulting toxicologist and reported to the ToxIC registry between 2010 and 2016 had ADE/ADR as the reason for consultation. Agents most commonly involved in ADE/ADRs included cardiovascular medications, antipsychotic medications, and antidepressants.
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October 2019

Perception and Practice Among Emergency Medicine Health Care Providers Regarding Discharging Patients After Opioid Administration.

Clin Ther 2018 02 20;40(2):214-223.e5. Epub 2018 Jan 20.

Department of Emergency Medicine, Lehigh Valley Hospital and Health Network/USF MCOM, Allentown, PA.

Purpose: This study aimed to determine the current attitudes, perceptions, and practices of emergency medicine providers and nurses (RNs) regarding the discharge of adult patients from the emergency department (ED) after administration of opioid analgesics.

Methods: A cross-sectional survey was administered at 3 hospital sites with a combined annual ED census of >180,000 visits per year. All 59 attending emergency physicians (EPs), 233 RNs, and 23 advanced practice clinicians (APCs) who worked at these sites were eligible to participate.

Findings: Thirty-five EPs (59.3%), 88 RNs (37.8%), and 14 APCs (60.9%) completed the survey for an overall response rate of 51.75%. Most respondents were female (95 [69.9%]). The factor ranked most important to consider when discharging a patient from the ED after administration of opioids was the patient's functional status and vital signs (median, 2.00; interquartile range, 2.00-3.50). More RNs (84 [96.6%]) than EPs (29 [82.9%]) reported that developing an ED policy or guideline for safe discharge after administration of opioids is important to clinical practice (P = 0.02). Only 8 physicians (23.5%) reported that they did not prescribe intramuscular morphine, and 15 (42.9%) reported that they did not prescribe intramuscular hydromorphone. EPs (7 [20.0%]) and RNs (3 [3.4%]) differed in regard to whether they were aware if any patients to whom they administered an opioid had experienced an adverse drug-related event (P = 0.01). Most EPs (24 [68.6%]) and RNs (54 [61.4%]) believed that the decision for patient discharge should be left to both the emergency medicine provider and the RN.

Implications: Most study participants believed that developing a policy or guideline for safe discharge after administration opioids in the ED is important to clinical practice. Only a few physicians reported that they did not prescribe intramuscular hydromorphone or morphine. Most participants believed the discharge decision after administration of opioids in the ED should be primarily determined by both the emergency medicine provider and the RN.
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February 2018

Loperamide-Induced Torsades de Pointes: A Case Series.

J Emerg Med 2017 Sep 26;53(3):339-344. Epub 2017 Jul 26.

Office of the Medical Examiner of Allegheny County, Pittsburgh, Pennsylvania.

Background: Loperamide is an over-the-counter, inexpensive, antidiarrheal opioid that can produce life-threatening toxicity at high concentrations. CASE REPORT 1: A 28-year-old man with a history of depression and substance abuse disorder (SUD) presented to the emergency department (ED) with shortness of breath and lightheadedness. He ingested large amounts of loperamide daily. The patient's initial electrocardiogram (ECG) demonstrated sinus rhythm, right axis deviation, undetectable PR interval, QRS 168 ms, and QTc 693 ms. He was administered intravenous sodium bicarbonate and magnesium sulfate and admitted to the intensive care unit, eventually developing Torsades de Pointes (TdP). He was given lidocaine and isoproterenol infusions, and an external pacemaker was placed. He was discharged in stable condition on hospital day (HD) 16. CASE REPORT 2: A 39-year-old woman with a history of hepatitis C, depression, and SUD was transported to the ED after reported seizure-like activity. The patient experienced TdP in the ED and admitted to ingesting large amount of loperamide daily. An ECG demonstrated sinus rhythm, right axis deviation, PR interval 208 ms, QRS interval 142 ms, and QTc 687 ms. She was administered intravenous magnesium, sodium bicarbonate, and isoproterenol. After intensive care unit admission, the patient experienced no further TdP and was discharged on HD 6. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians should proceed with caution when treating patients with loperamide toxicity. Even in asymptomatic patients and drug discontinuance, obtain consultation with a medical toxicologist, promptly treat ECG abnormalities aggressively, and admit all patients for further monitoring.
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September 2017