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American College of Medical Toxicology Fall 2009 Newsletter |
The newsletter is always looking for new material. Have an interesting story that you think would be of interest? A picture or photograph from a national meeting that you'd like to share? A story of toxicologic interest that you think would be important to disseminate? The newsletter is your voice - let it be heard!
If you have an interest in helping with the editorial process of the newsletter or if you have a request for a new feature, idea, content or image, please contact us anytime at newsletter@acmt.net.
Thank you - The Editors
Josef G. Thundiyil, Craig Smollin, Lewis Nelson |
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New and Noteworthy!
Congratulations to Dr. Rick Dart, who has been named to become president of the American Association of Poison Control Centers (AAPCC).
Congratulations to Dr. Steve Seifert, who has been elected to the board of AAPCC.
Congratulations to Drs. John Curtis and Jeff Nemhauser, who have been elected to the board of the American Academy of Clinical Toxicology (AACT).
ACMT members were a focus of a recent FDA advisory committee regarding acetaminophen hepatotoxicity. Dr. Lewis Nelson chaired the committee, and was joined by ACMT members Drs. Neal Benowitz, Paul Dargan, and Ed Kuffner (Ed Krenzelok was also an advisory committee panelist.) The minutes of the panel can be found here. (pdf link)
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President's Column
 | Expanding Our Boundaries Further: The Medical Toxicologist and Medication Safety
Erica L. Liebelt, MD, FACMT
President, American College of Medical Toxicology |
The field of medical toxicology interfaces with numerous specialties and disciplines, demonstrating the depth and richness of our subspecialty. Patient safety and quality improvement are not only becoming common every day 'buzz' words in the healthcare field, but the foundation for many changes in healthcare reimbursement, criteria for physician credentialing, and a new 'just culture'. Medication errors are a leading cause of adverse medical events in our hospitals today.
Why are medical toxicologists such a great fit for patient safety, and more specifically medication safety? We have the expertise and knowledge for evaluating the causes and managing the consequences of unsafe medication use. We have the same skills in evaluating workplace and environment safety. Our certifying examination now includes questions on medication safety. We are organizing a research consortium (ToxIC) for evaluating aspects of medication safety. Finally, many of our members are leaders of Pharmacy and Therapeutics/Safety Committees and Teams.
Medication safety has become an entire subspecialty in and of itself in the world of patient safety. A major focus is on systems analysis and redesign as the foundation of medication error prevention. The process of medication utilization is traditionally divided into 6 components: prescribing, transcribing, dispensing, administering, monitoring, and follow-up. There are numerous opportunities in each of these steps to contribute to quality improvement and patient safety initiatives.
- The medical toxicologist is in a unique position to investigate causes of, and help decrease the incidence of both medication errors and adverse drug reactions through our knowledge of medications, drug-drug interactions, and toxic reactions to medications.
- The medical toxicologist can assist in the development and review of standardized order sets and CPOE sets that involve medication prescribing, management, and therapeutic drug monitoring.
- The medical toxicologist can conduct research in improving medication systems' designs by looking at any of the 6 components delineated above. In addition, the research, development and implementation of new and different medication error reporting systems has the potential to demonstrate systems' improvement in medication safety and reduction in adverse drug events. Let's collaborate under ACMT's newly formed ToxIC (Toxicology Investigators' Consortium) and demonstrate our expertise and contributions in this field.
- The medical toxicologist can be an important member of the hospital's Pharmacy and Therapeutic Committee and/or Medication Safety Committee and/or Quality Improvement Council, helping to further develop your Medication Management System - believe me, once you start volunteering the opportunities will overwhelm you!
If you want to think even more outside the box, there are numerous other areas in the world of patient safety that can be focused specifically on medication safety:
- Health Information Technology (HIT): The current state of knowledge of clinical HIT with regards to medication safety is evolving at a rapid pace due to numerous and varied factors - improvement in reporting systems, improvement in outcome definitions of medication errors, increased vigilance and attention to detecting medication errors with systems other than self-reporting, and people's increased thirst for knowledge and vigilance in thinking about CPOE systems and medication safety.
- Human Factors Engineering: The human factors engineering paradigm proposes that the mechanism by which system design may improve patient safety outcomes is through healthcare provider (HCP) performance and the elimination of hazards; thus, design must support HCP performance and eliminate hazards. Examples: Why don't the 'Smart IV Pumps' beep when a High Alert is reached? Why are there numerous choices for IV tubing for different medications? Why is the font type so small on some medication syringes? Do different colored syringes really reduce errors in administering oral versus IV meds?
Many of you may know that I just recently finished a one year Executive Fellowship in Patient Safety at the Williamson Healthcare Leadership Institute at the Virginia Commonwealth University in Richmond, VA. The breadth of new knowledge, new skills, and new tools I have gained from this experience have provided me with numerous opportunities to enhance further the medication safety initiatives I am involved with at The Children's Hospital of Alabama. It has also allowed me to gain additional experience and use my toxicology knowledge in leading multidisciplinary teams evaluating and understanding processes of medication delivery, utilization, and safety in our hospital. In addition, I was just appointed Medical Director of Medication Safety for our hospital - a new position created to identify strategic priorities for improving the safety of the medication utilization and administration process at The Children's Hospital of Alabama.
However, you do not need to pursue yet more fellowship training to be an advocate for medication safety. Get involved and experience the changes and initiatives that are taking place in your institution. Medical Toxicologists need to expand beyond our traditional boundaries of managing acute overdoses. We need to look at new and different opportunities in the area of medication and patient safety where we can make improvements and a positive impact in the quality and safety of care delivered to our patients.
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Propofol
Use, Abuse, and Misuse
by William J. Holubek, MD |
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There has been much ado about propofol in the news recently with the Los Angeles coroner ruling Michael Jackson's death a homicide from 'acute propofol intoxication'.3 Many physicians may not consider propofol as a potential drug of abuse but in fact, there are numerous case reports of propofol abuse with many unfortunately resulting in death.
Propofol (2,6-disopropylphenol) is a commonly used xenobiotic for inducing general anesthesia and moderate sedation in operating rooms, surgical suites, intensive care units, and emergency departments. Other uses include the management of status epilepticus and delirium tremens, and as a treatment modality for chronic, migraine and tension headaches in selected pain clinics.
The same characteristics that make propofol an ideal xenobiotic for many clinical situations, may also contribute to its desirability as a drug of abuse. These include a quick onset of action (usually within 40 seconds), a short duration of action (3-5 minutes), and a lack of lingering sedative effects. In addition, some patients report pleasurable emergence effects from sedation with propofol including euphoria, relaxation, hallucinations, sexual fantasies, and disinhibition.6,11 The desire for these experiences was originally referred to as 'Diprivan-seeking' behavior (or psychological dependence) causing some abusers to inject up to a reported 100 times per day.4,7,9 A survey of anesthesiology departments with anesthesiology residency programs shows a fivefold increase in the incidence of propofol abuse from the 1990's to 2005.12 More worrisome is the 28% mortality rate (7 out of 28) it carries with it.
Mechanistically, propofol has been shown to enhance chloride current in GABAA channels, and at higher doses directly activate these channels while also inhibiting NMDA receptors. This NMDA antagonism, a similar mechanism of ketamine, may explain the origin of post-sedation hallucinations experienced by some.11 Studies have reported increased dopamine concentrations in the nucleus accumbens, which is part of the brain's mesocorticolimbic dopaminergic circuit of reward, and in vivo animal studies strongly suggest an abuse potential of propofol.11 Despite these animal studies, human case reports have only described the development of strong cravings for propofol by the abuser and continued use despite adverse personal consequences, suggesting a behavioral and/or psychological dependence.4 Studies that suggest a withdrawal syndrome from propofol are difficult to assess because they report on very ill patients with advanced diseases being administered multiple medications.5 To date, there remains no clear evidence to support a tolerance or physiological dependence to propofol.7,8,9 |
References
- Chao TC, Lo DST, Chui PPS, Koh TH. The first fatal 2,6-di-isoprophylphenol (propofol) poisoning in Singapore: a case report. Forensic Sci Int 1994;66:1-7.
- Diprivan [package insert]. Wilmington (DE): AstraZeneca Pharmaceuticals LP; 2005.
- Duke, Alan. Michael Jackson's death was a homicide, coroner rules. CNN 31 August 2009
- Follette JW, Farley WJ. Anesthesiologist addicted to propofol. Anesthesiol 1992;77:817-818.
- Fulton B, Sorkin EM. Propofol: an overview of its pharmacology and a review of its clinical efficacy in intensive care sedation. Drugs 1995;50:636-657.
- Iwersen-Bergmann S, Rosner P, Kuhnau HC, et al. Death after excessive propofol abuse. Int J Legal Med 2001;114:248-251.
- Kirby RR, Colaw JM, Douglas MM. Death from propofol: accident, suicide, or murder? Anesth Analg 2009;108:1182-1184.
- Klausz G, Rona K, Kristof I, Toro K. Evaluation of a fatal propofol intoxication due to self administration. J Forensic Leg Med 2009;16:287-289.
- Kranioti EF, Mavroforou A, Mylonakis P, Michalodimitrakis. Lethal self administration of propofol (Diprivan): a case report and review of the literature. Forensic Sci Int 2007;167:56-58.
- Leikin JB, Watson WA. Post-mortem toxicology: waht the dead can and cannot tell us. Clin Toxicol 2003;41:47-56.
- Roussin A, Montastruc JL, Lapeyre-Mestre M. Pharmacological and clinical evidences on the potential for abuse and dependence of propofol: a review of the literature. Fundamental Clin Pharmacol 2007;21:459-465.
- Wischmeyer PE, Johnson BR, Wilson JE, et al. A survey of propofol abuse in academic anesthesia programs. Anesth Analg 2007;105:1066-1071.
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The pharmacokinetics of propofol follow a three compartment model: plasma, rapidly equilibrating tissues (brain), and slowly equilibrating tissues (adipose). Propofol undergoes rapid and extensive hepatic metabolism producing inactive, water-soluble sulphate and glucuronide conjugates that are renally excreted. Common side effects from the use of propofol include hypotension (that may be rate and dose dependent), bradycardia, apnea, bronchodilation, and decreased cerebral blood flow. If apnea occurs after a standard induction dose in adults, it is short-lived, lasting less than 30 seconds in 7% of patients, 30-60 seconds in 24% of patients, and more than 60 seconds in 12% of patients.2 Some less common and rare side effects include epileptiform movements, convulsions, myoclonia, anaphylaxis/anaphylactoid reactions, pancreatitis, rhabdomyolysis and green colored urine.2,5
After an intravenous induction dose, patients quickly lose consciousness at serum levels between 1.3-6.8 mcg/mL, and regain consciousness within 5-10 minutes at serum concentrations 1-2.5 mcg/mL.6,8,9 The rapid distribution to the highly perfused brain and hepatic metabolism account for the steep drop in propofol concentration. During maintenance infusions of propofol for prolonged sedation during surgeries or ICU stays, an equilibrium between plasma and the highly perfused tissues (brain) create steady state propofol concentrations that range from 1.1-1.3 mcg/mL.5 Longer infusions of propofol are associated with longer times to awakening due to significant body tissue stores of propofol.2,5
When dosing propofol in adults, it is important to keep in mind two points. The first is that elderly (>55 years old), debilitated and ASA III/IV patients require lower doses to achieve the same level of sedation or anesthesia. In addition, they experience higher peak plasma concentrations for a given dose, which may predispose them to adverse cardiorespiratory effects.2 The second is that premedicating a patient with an opioid or benzodiazepine may increase the sedative or anesthetic effect of propofol, and may also result in more profound hypotension and adverse cardiorespiratory effects.
In contemplating the self abuse of propofol and its potential to result in death, one important question to consider relates to the following: Given the rapid clinical onset and rather large volume of solution used to induce sedation, is it possible for someone to self-inject enough propofol to cause respiratory arrest and death, or would they lose consciousness before administering a lethal dose?
To help answer this question we examine some published case reports of propofol related deaths. Postmortem detection and interpretation of particular xenobiotics is littered with complex factors not limited to postmortem redistribution and metabolism and site of sample but also with antemortem factors such as dose, time and route of administration.10 The current case reports of propofol deaths in the literature report postmortem samples drawn from femoral blood with concentrations ranging from 0.22-5.3 mcg/mL.1,6,7,8,9 |
The environment in which a body is found is paramount in determining the manner of death in these cases. In one case, a woman was found dead in her home with recent needle-like puncture wounds on her antecubital fossa.7 Syringes, needles, and two empty 20mL 1% propofol vials were found tied up in a bag outside her house. Her blood propofol concentration was 4.3 mcg/mL. This case was ruled a homicide as it was deemed impossible for someone to self-administer this amount of propofol, dispose of the paraphernalia outside the house, and then return inside the house only to collapse. Three years later a male nurse was found guilty of first degree murder and sentenced to life in prison without parole.
Other cases describe scenes of apparent self-administered lethal overdose of propofol. A nurse anesthetist who was a known abuser of propofol was found dead in bed surrounded by 14 empty 1% propofol ampules and two 20 mL syringes filled with propofol. A partially emptied 20 mL syringe of propofol was found still attached to a cannulated thigh vessel.8 She had a postmortem propofol femoral blood concentration of 1.31 mcg/mL along with an ethanol concentration of 78 mg/dL. In another case, an anesthesiologist known to be a propofol abuser was found dead in a hospital dormitory with the door locked from the inside kneeling on the floor face-down surrounded by three empty 20mL vials of 2% propofol.9 She had intravenous catheters secured in both wrists. Her postmortem propofol femoral blood concentration was 2.4 mcg/mL. The cause of death was propofol abuse.
Some authors have proposed that a 'very rapid injection' of an appropriate induction dose of propofol may cause prolonged apnea, extreme hypoxia, hypotension, airway obstruction and/or oxygen desaturation with consequent cardiovascular collapse and death.2,6,7,8 In fact, the package insert of propofol specifically warns against rapid, bolus injection to minimize adverse cardiorespiratory depression. In addition, combining propofol with other sedative-hypnotic xenobiotics will undoubtedly potentiate adverse cardiorespiratory effects.
In conclusion, propofol abuse appears to be increasing and carries a high mortality rate. It remains very difficult to interpret postmortem concentrations alone but the environment in which an individual is found may provide critical information in helping determine cause and manner of death.
Acknowledgments: I would like to thank Mary Ann Howland, Lewis Nelson, and Kathy Ferguson for their constructive critique and input.
ACMT speaks out on the dangerous hazards of propofol abuse. Check out the press release from July 28, 2009. |
The 2009 ACMT Pre-Meeting Symposium
At The North American Congress of Clinical Toxicology, San Antonio TX
Tuesday, September 22, 2009
Network News Toxicology: An Examination Of The Media's Portrayal Of Toxicology
American society is dominated by mass media in various forms. It is arguable whether this impact is positive or negative, but all agree the media holds a strong influence on our society and its view of the world. Medicine is not immune to the media's strong sway. As a relatively small and often misunderstood specialty, the media's representation of medical toxicology topics may have a great impact on people's opinion of us and on the beliefs of our patients. Notably, the coverage of toxicology related topics may not always reflect the complexities and rapidly changing body of evidence related to the field. The 2009 ACMT Pre Meeting Symposium will examine the media's depiction of toxicology.
The goal of this pre-symposium is to explore how recent events and media coverage of those events have shaped our specialty, influenced the layperson's opinion of medicine, and altered society as a whole.
At the end of the pre-symposium, the learner will be able to:
- Critically appraise the media coverage of recent toxicology related subjects for content, accuracy and truth.
- Review recent literature and the present body of knowledge associated with toxicology subjects recently covered by the media.
- Recognize toxic mechanisms and symptoms related to toxins recently covered by the media.
- Integrate newly learned concepts and ideas into the daily practice of medical toxicology.
Keynote
Through The Looking Glass: The Media's Perception Of Medicine And Toxicology
Glenda Wolin, Associate City Editor for the San Antonio Express News
Media Down Under
Naren Gunja, MD, MBBS, FACEM
Deputy Medical Director & Toxicologist
New South Wales Poisons Information Centre
and The Children's Hospital at Westmead
Military Toxicology in the Media
Dave Barry, MD, FACMT
Program Director, Emergency Medicine Residency
Naval Medical Center Portsmouth
The Toxicology of Imports: Worldwide Toxicology in the Media
Chuck McKay, MD, FACMT
Director of Medical Toxicology and Associate Professor of Emergency Medicine, Hartford Hospital
University of Connecticut School of Medicine and the Connecticut Poison Control Center
Alternative Medical Therapies in the Media
Asim Tarabar, MD, FACMT
Assistant Professor, Yale University
Don't Cry Over . . . Toxic Spills: A Critical Look At Accepted Evidence And Media Coverage
Patrick Daubert, MD
Assistant Professor and Assistant Medical Director, Sacramento Division, California Poison Control System
Program Director, Medical Toxicology
Director of Clinical and Medical Toxicology Education
Department of Emergency Medicine
University of California, Davis
The Newest Craze: The Media's Fascination with Weight Loss
Trevonne Thompson, MD
Assistant Professor of Medicine and Pediatrics
Associate Director of Medical Toxicology, University of Chicago
From Mercury to Polonium: Occupational/Environmental Toxicology in the Media
Michael Holland, MD, FACMT
Clinical Assistant Professor, Dept of Emergency Medicine
SUNY Upstate Medical University
Medical Toxicologist, Upstate NY Poison Center
Other ACMT Events at NACCT
Be sure to check out this schedule, the most updated grid of times and locations of all ACMT events. This will be your one-stop source to find out where and when . . .
| Tuesday September 22nd | 12pm - 1pm | ACMT Business Meeting |
| 4:30pm - 6:30pm | ACMT CPC Competition |
| 7:00pm - 8:30pm | ACMT Fellows Reception
by invitation only |
| Thursday September 24th | 8am - 10am | ACMT Scientific Symposium
Genetic Susceptibility in Toxic Exposures
Emanuela Taioli, MD, PhD
Lee S. Newman, MD, MA
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| 2:30pm - 3:30pm | The Ellenhorn Award
Recipient: Steven Marcus
Presenter: Keith Burkhardt |
| Friday September 25th | 12pm - 1:30pm | ACMT Fellows-in-Training Lunch
The Bradford-Hill Criteria
Richard Wang, CDC
by invitation only |
| 1:30pm - 2:30pm | ACMT Fellows-in-Training Roundtable
The Industrial Toxicologist
Jeffrey Brent - Moderator
Daniel Goldstein
Sam Jackson
Ed Kuffner |
| Saturday September 26th | 7:00am - 1:00pm | AACT/ACMT LLSA Review
Kurt Kleinschmidt
Chris Tomaszewski
Michael Policastro
Diane Callelo |
| 11:00am - 1:00pm | ACMT Practice Symposium
The Toxicologist and Drug Safety
Ann-Jeanette Geib, MD - Moderator
Sam Jackson
Keith Burkhart
Richard Dart |
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| New ACMT Board Member |
New ACMT Board Member |
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Stephen W. Munday, MD MPH MS |
Dr. Munday completed his Bachelors Degree at the University of Florida in 1983 followed by his M.D. Degree at the University of Florida in 1987. He then did a one year Internal Medicine Internship at the Naval Hospital Oakland, California in 1988. He completed a Public health Residency at the University of California, San Diego in 1995 while concurrently obtaining an MPH in Occupational Health and Epidemiology at San Diego State University. Dr. Munday went on to complete an Occupational & Environmental Medicine residency at the University of California, Irvine while at the same time obtaining an MS in Environmental Toxicology. From 2000 through 2002 he completed a Medical Toxicology fellowship at UCSD. Dr. Munday has been an active member of ACMT since he joined at the start of his Medical Toxicology fellowship and was involved in teaching the Agents of Opportunity course as well as the Medical Toxicology Board Review course. He recently joined ACMT's Education Committee and is one of the Directors for the 2012 Medical Toxicology Board Review Course. Dr. Munday is board certified in Medical Toxicology, Occupational Medicine and Public Health.
Dr. Munday is a Clinical Assistant Professor at UCSD and is also a Consulting Toxicologist for the California Poison Control System, San Diego Division. Dr. Munday is also the Chief of Environmental and Preventive Medicine at the Sharp Rees-Stealy Medical Group. He has been the Public Health Officer for Imperial County, California since 2004.
Dr. Munday's vision for the future of ACMT: "I want to strengthen the training opportunities in the occupational aspects of Medical Toxicology for fellows and promote our specialty among the Preventive and Occupational Medicine communities. I hope to do this by improving communication with organizations such as the American College of Occupational and Environmental Medicine (ACOEM)".
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Ann-Michelle Ruha, MD |
My interest in toxicology began during my Emergency Medicine Residency at Morristown Memorial Hospital in New Jersey, where I found the most exciting patients to care for were those presenting with an overdose. My curiosity about envenomations drew me to Phoenix, where I completed my fellowship in Medical Toxicology. I have since had the privilege of practicing full time toxicology in Phoenix and have also served as the director of the Medical Toxicology Fellowship Program at Banner Good Samaritan Medical Center for the past four years. Of the many aspects of my job that I enjoy, it is my experience with toxicology fellows-in-training that drives me to further contribute to ACMT and the Medical Toxicology community.
Many graduating fellows desire careers as full time toxicologists. While opportunities are increasing, they are still limited. In too many cases, Medical Toxicologists are viewed as emergency, pediatric, or occupational physicians with an interest in toxicology, rather than true specialists, and as a result must earn a living in their primary field of training, while essentially volunteering their toxicology expertise. Additionally, other physician specialists and organizations are often unfamiliar with Medical Toxicology as an ABMS-recognized subspecialty. While this situation is improving due to the tireless work of current and past leaders within ACMT, we still have a long way to go. My goal as a member of the ACMT Board of Directors would be to further advocate our specialty and help expand the opportunities available to our members. This can only occur through continued education and demonstration to others that as true experts in the diagnosis and treatment of poisoned patients, we save both lives and health care costs.
My previous involvement in ACMT includes participation in committees including the Board Review Task Force, Project Participation Guidelines Committee, and Education Task Force. I am a member of the Editorial Board for the Journal of Medical Toxicology, and now also serve as the Section Editor for Case Reports. I have lectured at NACCT and the ACMT Spring Course, and am organizing a course for the lay public during the ACMT Spring Course in 2010. I have thoroughly enjoyed my activities within ACMT and hope to provide greater contributions in the future. |
 | ACMT Awarded New 5 Year Cooperative Agreement with ATSDR / CDC
Paul Wax, ACMT Executive Director
Erica Liebelt, ACMT President |
ACMT has just been informed that we have won a new 5 year Cooperative Agreement with ATSDR / CDC for the National Environmental Medicine Education and Consultation Project (NEMECP). A hearty congratulation is extended to former ACMT President Michael Kosnett, MD, MPH, who has now for the 3rd time engineered a successful 5 year cooperative agreement application for funding to CDC. Bravo!
This was a competitive application process and new funding was in no way assured. Our previous cooperative agreement ended on August 31, 2009. The new cooperative agreement begins September 30, 2009 and runs to September 29, 2014. In addition to Michael Kosnett, the PI on this cooperative agreement, an enthusiastic thank you is also extended to to Charles McKay, MD, who has served as the National Program Director for the Cooperative Agreement and related ATSDR activities since 2006. Most importantly, ACMT’s successful record for extramural funding with ATSDR / CDC is due to the efforts of ACMT members who have participated in ATSDR funded activities over the last 10 years. More than 100 ACMT members have lectured in an ATSDR-sponsored course or participated in a regional consultation. The successful track record of ACMT is due to the high quality of our educational efforts and clinical consultations, which have certainly caught the eye of ATSDR / CDC. Given the extremely competitive environment for extramural support, obtaining continued funding is a testament to the superior contributions and support of ACMT members.
ACMT plans to continue to actively engage members (including new members) in the activities of the new cooperative agreement over the next 5 years. The ACMT-ATDR consultation network operates regionally across the 10 EPA / ATSDR regions. ACMT members from each of these 10 regions will be receiving shortly additional information about opportunities for leadership roles and involvement in this cooperative agreement.
In addition, we will have a meeting at NACCT in San Antonio that will discuss work plans for the coming year on this ACMT-ATSDR agreement. The meeting will be on Friday September 25 from 11 AM - 12:30 PM in the Presidio C room on the 3rd Floor in the Grand Hyatt. All ACMT members are welcome to attend.
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| Spring Course 2010 |
Special Poster Session |
The 8th Annual ACMT Spring Conference
Mother Natures' Gift to Toxicologists (pdf)
Exploring the Animal, Botanical & Mineral Toxic World
March 12-14, 2009
Hyatt Regency Resort and Spa, Gainey Ranch, Scottsdale AZ
Day 1 - "Killer Weed" - The Ethnobotany of Toxicology
Keynote: The Ethnobotany of Plants
Walter and Memory Lewis, PhD
Day 2 - "ToxoKnowledgy" - Animal Envenomations
Keynote: The Pathophysiology of Rattlesnake Venom
Steve Curry, MD FACMT
Day 3 - "ToxRocks" - Mining and Metallurgy
Keynote: Eronite, Asbestos and Mesothelioma
Nicholas J. Vogelzang, MD
Hightlights include:
- Fellow-In-Training Research and Open Mike Presentations
- Professional Development Symposia
- Special Session - Research You May Have Missed Elsewhere
- A visual, auditory and tactile stimulus room
- Guided trips to the Botanical Gardens, the Arizona Zoo and more!
- And plenty of time to enjoy the sun . . .
Be sure to go to the ACMT Website to register now.
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Research You May Have Missed at Other Meetings
For work so nice it's presented twice
2010 ACMT Spring Conference Special Poster Session
Saturday March 13, 2010
Daniel Rusyniak, Chair, ACMT Research Committee
As medical toxicology spans the breadth of medicine, some of the most significant research done in our field is presented at meetings not commonly attended by medical toxicologists. In an attempt to provide ACMT Spring Conference attendees an opportunity to interact with cutting edge medical toxicology research, future spring conferences starting with 2010 will include a Scientific Poster Session for Research You May Have Missed at Other Meetings.
Criteria for accepted posters include the following:
- The material must have been previously presented.
- The material must be relevant to the field of medical toxicology.
- Case reports will not be accepted.
- The lead investigator or a co-investigator must attend the meeting to present their work in person.
Abstracts may be submitted in their previously submitted format. There is no required standard format. Please submit to info@acmt.net.
Abstract submission deadline October 15th, 2009.
For further questions or inquires please contact:
Daniel Rusyniak, MD
Chair, ACMT Research Committee
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ACMT's 1st Forensic Toxicology Course In association with The Society of Forensic Toxicologists
November 18 & 19, 2009
Sheraton Inner Harbor Hotel Baltimore, MD
A 21 year-old driver is arrested by police after failing field sobriety tests following a two-vehicle collision with injuries to the other party. The driver is agitated and admits to a “couple” of drinks about 1 hour earlier. Two breath alcohol measurements 30 minutes apart at the police station register 0.150 and 0.135 g/dL.
The other involved party sues this person for medical bills, pain and suffering, ongoing medical care, and lost wages. Both parties sue the bar where the 21 year-old was drinking, stating that the bartender should have recognized signs of intoxication and not served him.
- What was his BAC at the times of the crash and last ethanol service?
- What are the visible signs of intoxication that police, bartenders, and others are expected to recognize?
A forklift operator has a crash at work, with significant property damage. The employer sends him to an occupational health provider for “post-accident” drug and ethanol testing, as indicated in his employment contract. A urine test returns positive for cannabinoids, with confirmation of Δ9-tetrahydrocannabol carboxylic acid at 100 ng/mL. When interviewed, the employee admits to using marijuana occasionally, with the last use on the weekend before the Tuesday accident. The employer fires the worker and the State denies unemployment benefits. The employee brings suit, claiming this is an arbitrary and retaliatory action because he had been trying to “start a union.”
- What are administrative workplace standards regarding positive drug tests?
- What correlation is there between urine cannabinoid measurements and impairment?
- What are the data addressing lingering impairment issues?
ACMT is offering this exciting course covering many practical issues at the interface of medical and forensic toxicology. We expect that both toxicologists-in-training, as well as seasoned medical and forensic toxicologists will learn from and enjoy this intensive review of the literature informing our opinions regarding ethanol and cannabinoid intoxication. This will be information you can use to expand and improve your consultative practice.
Register now! – the conference is filling up quickly!
Click here for the course brochure.
We plan that this course will be the first of many forensic toxicology courses that will alternate with the fall board review course. We will be using the input from our members to help direct the content of these courses, so please make your thoughts known to Chuck McKay, Lewis Nelson, or Paul Wax.
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| Journal of Medical Toxicology |
Special Announcement about JMT |
Exploring the Journal of Medical Toxicology
by Craig Smollin
Is the occurrence of seizures associated with Tramadol use dose-independent?
In the June edition of the Journal of Medical Toxicology, Haleh Talaie et. al. explore the relationship between the dose of tramadol ingested and the occurrence of seizures. In this cross-sectional study, 215 patients with a history of tramadol use were recruited during a 5-month period. Patients with a history of co-ingestions of other drugs, addiction, convulsive disorders, renal disease and head trauma with abonormal EEG or brain CT scan were excluded. All patients were observed for at least 24 hours after admission. Of the 132 patients included in the study, seizure occurred in 61 (46.2%) of patients. The authors noted that there was no difference in the mean tramadol intake between those patients who developed seizures and those that did not. The authors thus postulate that the incidence of seizures with tramadol in humans is not dose dependent.
See the article here.
Also, follow What's Coming to JMT at the editor's blog.
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SPRINGER TO BECOME JMT PUBLISHER IN 2010
Leslie R. Dye, Associate and Managing Editor, JMT
The ACMT Board of Directors and the Journal of Medical Toxicology (JMT) Editorial Board are very pleased to announce that, starting with the 2010 Issue #1 of JMT, the Springer Publishing Company will become JMT's new publisher. Founded in 1842, Springer is truly one of the giants in medical and academic publishing, publishing 2000 journals and more than 6500 books each year. We are thrilled to have this opportunity.
This change in publishers offers ACMT several distinct advantages as we endeavor to make JMT a truly outstanding journal. One of the most significant advantages is Springer's ability to disseminate JMT to libraries throughout the world through Springer's many national and international consortia agreements. JMT's greatly enhanced library penetrance through Springer-Link will significantly increase the readership of JMT, as well as increase JMT's impact factors, with the goal of securing more high quality submissions.
In addition, Springer offers real time online publication. Starting in 2010, after an article has been accepted, formatted, proofed, and finalized, it can be electronically published online within 21 days, far sooner than it will appear in print form. This quick turnaround time is a major advantage as articles will be e-published (and indexed) a number of months ahead of the print publication date. We plan to continue to print a quarterly journal, but our capacity for quick turn around and our ability to increase the number of articles published is greatly enhanced. Finally, Springer offers public relations support and will help prepare press releases on key articles designated by the Editors as newsworthy.
While we are forever indebted to Penn Press, our current publisher, for enabling ACMT to launch JMT in 2005 and for providing wonderful support over the last five years, we determined that the advantages of going with a larger publisher were in the best interest of the journal and its future. This move will also help improve the financial bottom line of JMT.
We are excited to enter this new partnership and look forward to continued improvement in our journal. We appreciate the extraordinary efforts of our members to make the journal a success. Because of the submission of manuscripts and the quality reviews from our members, the journal has thrived. While we anticipate that this transition will be seamless, from the standpoint of submissions, reviews, and article processing, please contact me with any questions or comments.
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The California Poison Control System and Funding Woes
Poison centers have provided information and advice to the people and health care providers of the United States for years. Numerous studies have demonstrated them to be resource efficient and cost saving to our health care system. They can prevent unnecessary emergency department visits and 911 ambulance calls. It is likely that they may save lives in certain situations, alert officials to outbreaks of either accidental or intentional poisoning, helping to limit further exposures. And yet, with all their potential benefits, funding problems for poison centers around the country are increasing.
The reasons for poison center funding crises are multifactorial, but most commonly result from a lack of information to political figures. Most funding for centers includes some combination of state, federal and local sources, occasionally with private contracts or grants. In recent years, most centers have seen a modest increase in federal money, while state contributions have dwindled. When the economy sputters, as in our current recession, poison centers become threatened. This is what has now occurred to the California Poison Control System (CPCS).
The CPCS is a unified system consisting of four divisions providing poisoning advice and management to the state of California. It has been in operation since massive consolidation of statewide poison centers occurred in 1997. Operating sites now include San Diego, Sacramento, San Francisco and Fresno/Madera. The system is administered under the University of California San Francisco (UCSF) School of Pharmacy, Department of Clinical Pharmacy with an administrative office in San Francisco. All staff are currently employees of UCSF.
The system answers approximately 320,000 information and exposure calls each year, shared approximately equally among the four sites. Each site uses the integrated data system for documenting and viewing cases throughout the state, and a linked phone system to route calls to the nearest available information specialist. All sites utilize the same management and triage guidelines. There is a managing director and medical director at each site with enough FTE support to satisfy American Association of Poison Control Centers (AAPCC) accreditation criteria for population and call volume. Over 85% of the CPCS budget goes toward staff salaries. We currently employ 29 CSPI pharmacists, 5 CSPI nurses, and 10 poison information providers.
Since its inception, the CPCS has been predominantly funded by a changing mix of state and federal funding. At its beginning in 1997, the state was able to profit from economies of scale by investing in one poison center system in California that was less expensive than several individually operating centers. Staffing decisions on numbers needed to answer calls was based on call volume as established by the AAPCC. Four sites were chosen to allow for regional expertise regarding flora, fauna, and knowledge of hospital capability. It was understood that with the vast majority of budget devoted to staff, and staff numbers dependent on total call volume, four sites made sense since staffing would be the same as with a model of one central location, and four sites provided redundancy in the event of natural disaster or power outage.
Although CPCS call volume has increased annually since 1997, state funding has dropped as the economy changed, most significantly in the past 4 years. As state revenues have declined largely due to the recession, state legislators have directed CPCS to seek funds elsewhere including federal, tobacco tax funds and charitable sources. No help is offered for this effort. Additionally, both the California Legislature and Governor’s Office have not supported CPCS in obtaining funds from those entities benefitting financially from CPCS services (i.e. health plans, insurance companies, hospitals). Several legislative bills which would have imposed fee taxes on these entities as well as a telephone surcharge assessment have all met an early demise.
Another unexpected problem that has plagued CPCS state funding is the increase in federal money in past years. As state lawmakers learned the CPCS was receiving money from HRSA sources, they were able to somewhat justify to their constituents cutting back state general funds.
Then the recession hit California two years ago. Beginning in 2007, the state began to tighten all budgets. While many state programs were forced that year to absorb 10% budget cuts, the CPCS wound up with a 15% cut. But in the 2008 and 2009 budget, the deficit became much more severe, and while the most recent budget revision threatened complete elimination of our state funds, we wound up with a 50% drop in general fund support. It will only be with the help of some matching Federal funds this year, if this occurs that we will be able to continue our service in present form for the rest of this fiscal year. A campaign to the media, political figures, our callers, and to the Governor’s office did help rescue the CPCS from certain closure, as the original proposal was to cut 100% of the state’s funding. Many other public assistance health care programs in the state have been completely eliminated this year, such as state funded health insurance for many low income children. Many large health systems we reached out to for support this summer cited higher funding priorities than poison information, even though they admitted heavy use of our services. It is quite possible that another year of statewide budget cuts will completely eliminate our state general fund support.
So where does this leave poison centers in the current economy? Many centers have struggled as we have, and some have recently closed. Increasing HRSA funding has helped some centers bridge gaps, but states have further cut funding in anticipation. Several options exist:
- Increased federal funding. There is hope that the new health plan proposed by the Obama administration might provide further support for poison centers. Unfortunately, administrative hurdles of federal support are now becoming more apparent to poison centers and are certain to increase if federal money is continued. This type of funding might also be cyclical depending on the economy and politics.
- Diversification into private markets. Several poison centers around the country already have significant portfolios invested in private contracting. These sources of income work best when a center is given flexibility by its parent organization with low overhead fees. In state- or university-supported centers such as the CPCS, large overhead fees and bureaucratic administrative systems can make private contracting problematic.
- Changing the business model. Presently, the AAPCC mandates certain criteria for “certification” of poison centers. Although these standards are generally considered worthwhile by most poison center advocates, it is possible that different models of poison information delivery could be cost efficient and effective. For example, the CPCS has discussed in recent meetings the more widespread use of poison information providers or non-licensed personnel operating under approved protocols. Currently, all providers must work directly with licensed staff. If protocol use was expanded, it is possible that non-licensed staff could provide much information at a much lower cost. It is also possible that extending CSPI staff to off-site working environments could be cost saving.
- Consolidation. This is the option that no one except those without knowledge of how a poison center works can support. Staff salaries are by far the most expensive part of a poison control center’s budget, and the staff size is dependent on call volume. As we have seen in our recent rash of budget tightening, as staff size decreases and call volume per specialist increases, this will be accompanied by a higher number of dropped calls and a decrease in specialist job satisfaction.
In closing, it is my belief that poison centers can only survive the next decade by adjusting our business model, and to do this we must adjust our expectations. In the past ten years, hospitalists have taken over much of the institutional care of patients in most medical centers. This was met by patient and physician concerns about “continuity of care” and always seeing a different health care provider. But expectations have adjusted in the name of possibly more cost efficient and effective care. In the same way, poison centers must forge a new model of providing poison information to survive.
Richard F. Clark, MD
Medical Director, San Diego Division of the California Poison Control System
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| Healthy People 2009 |
Stories You May Have Missed |
Healthy People in a Healthy Environment
2009 National Environmental Public Health Conference
October 26 - 28, 2009
Sheraton Atlanta Hotel, Atlanta, GA
Who: People interested in the interrelationship between the environment and health: federal, state, tribal, and local public and environmental health professionals, academic researchers; physicians, nurses, and other healthcare professionals; representatives from communities and organizations; policy and decision makers.
What: Exploring new research and innovative practice in ecosystems and public health, healthy places and communities, sustainability, public health and chemical exposures, and more.
Organized by:
Centers for Disease Control and Prevention's National Center for Environmental Health and the Agency for Toxic Substances and Disease Registry & National Environmental Health Association
ACMT is a member of the organizing committee and is represented by our Executive Director, Paul Wax, MD.
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Explore how the media covers stories with a toxicology bent. Check out these recently published stories. If you find anything of interest, please forward them to the newsletter editors. Don't forget to check out the automatically updating Toxicology in the News on the website.
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 | Global Toxicology and ACMT's International Ambassador Program
Making All The Right Connections
Rais Vohra, MD and Nadeem Al-Duaij, MD |
International health is currently enjoying a surge in popularity among both trainees and practicing clinicians. This multifaceted, multidisciplinary subspecialty has assumed a diversity of forms and continues to evolve as collaborators from many backgrounds explore new challenges and opportunities. Fortunately, emergency medicine and toxicology have also witnessed a rising number of clinicians who are seeking international clinical experiences.
To better define and fulfill the interests of members who have an interest in global health, the ACMT's International Committee (IC) has been busy with several exciting new initiatives. Among the objectives of the ACMT IC is the enrichment of medical toxicology in developing countries by assisting local advocates, and encouraging international collaborations focused on regions where clinical toxicology is just beginning to take root.
One of the committee's initial steps has been to identify local and regional experts from around the world who can function as contact persons, educators, and researchers. These dedicated volunteers are asked to fulfill several duties while serving in their roles as International 'Ambassadors' to the ACMT:
- Represent ACMT's educational goals locally and represent their national medical toxicology society (or similar groups) within ACMT
- Collaborate with other clinicians, interest groups, governmental agencies, and academic institutions to promote the development of medical toxicology programs and best practice initiatives within their countries and regions
- Participate in local or regional conferences and offer educational sessions
- Prepare annual reports on the status of medical toxicology in their regions
The committee has also recognized several Regional Directors to help connect Ambassadors and ACMT members with one another in international education and research efforts. These officers are listed below along with their contact information. ACMT members who are interested in collaborating with others, teaching internationally, or traveling to visit these countries or regions are welcome to contact the ambassadors and regional directors listed below. This list is expanding as we identify more key personnel worldwide who are interested in working with the ACMT membership to promote medical toxicology globally. It is hoped that, eventually, toxicologists from around the world can participate in this exciting and vital endeavor in the area international health, under the auspices of the ACMT.
Please refer to the ACMT International Committee's web page for more details and updated contact information on all of the dedicated members taking part in this collaboration. And stay tuned here for more updates and news from this rapidly organizing group of dedicated toxicologists from around the world.
ACMT International Committee Ambassadors and Regional Directors
Americas Region
Regional Director: Javier Waksman
Brazil Ambassador: Carlos Collares
Mexico Ambassador: Janett Santos
Western Pacific Region
Australia Ambassador: Naren Gunja
Singapore Ambassador: Dong Haur (DH) Phua
Eastern Mediterranean Region / Africa Region
Regional Director (North Africa / Middle East): Ziad Kazzi
Regional Director (Africa Region): Josef Thundiyil
Saudi Arabia Ambassador: Mohammed Al-Helail
United Arab Emirates Ambassador: Jane Terris
Israel Ambassador: Didi Bentur
Europe Region
Regional Director: David Wood
Germany Ambassador: Philip Walson
South Asia Region
Regional Director: Rais Vohra
Nepal Ambassador: Kiran Manandhar
Sri Lanka Ambassador: Indika Gawarramana
India Ambassador: V.V. Pillay
Thailand Ambassador: Summon Chomchai
Upcoming international courses in medical toxicology
- Asia Pacific Association of Medical Toxicology - Beijing, China, Oct 19 - 22, 2009
- Toxocon-5 (pdf) - Sponsored by the Indian Society of Toxicology - Nov 7 & 8, 2009
- The First Joint American-Israeli Medical Toxicology Conference (pdf) - Haifa, Israel - November 16 & 17, 2010
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ACMT Newsletter Photo Caption Contest!
Welcome to the ACMT newsletter contest. No cost to enter! Submit as many times as you want! Win acclaim and prizes!
Rules for caption contest . . . - Email a caption for the picture (to the left) to web@acmt.net
- Do this before December 15th, 2009
- Repeat, as necessary
The winner will be published in the next edition of the newsletter, Winter 2010.
 | Congratulations to our second winner . . . Asim Tarabar, for his caption "But she's got a great personality . . . " |
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