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Powers JG, McCue JY, Handrigan MT, Stroh G, Black ND, Darracq MA, Buttke DE, Hilger KA, Chew SE, Lance WR, Kirschner SM, Ehrlich R, Hall E. PROTOCOL FOR HUMAN EXPOSURE TO OPIOIDS AND CONCENTRATED MEDETOMIDINE USED IN FIELD APPLICATIONS. J Zoo Wildl Med 2024; 54:873-878. [PMID: 38252014 DOI: 10.1638/2022-0106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2023] [Indexed: 01/23/2024] Open
Abstract
Wildlife professionals routinely use potent sedatives and anesthetics when chemically immobilizing wildlife and zoo species in remote environments. Accidental exposure to these prescription veterinary drugs is rare but could be rapidly fatal. Commonly used agents include opioids and α2 adrenoreceptor agonists. These drugs can be reversed with specific antagonists; however, they are often not approved for human use. The protocol created here can be used by wildlife health professionals in a field setting with basic human emergency medical response training in coordination with local Emergency Medical Services (EMS). Key components include, building local relationships between EMS and wildlife professionals, focused EMS training, administering opioid and α2 adrenergic antagonists off label, and local evacuation procedures. This framework could allow wildlife management agencies or zoos to mitigate the risk of human exposures to these commonly used drugs, significantly improving occupational safety in an otherwise high-risk environment.
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Affiliation(s)
- Jenny G Powers
- National Park Service, Natural Resources Stewardship and Science, Fort Collins, CO 80525, USA
| | - James Y McCue
- University of California San Francisco, Fresno Medical Education Program, Department of Emergency Medicine, Fresno, CA 93701, USA,
| | - Michael T Handrigan
- National Park Service, US Forest Service, Emergency Medical Services, Washington, DC 20240, USA
| | - Geoff Stroh
- University of California San Francisco, Fresno Medical Education Program, Department of Emergency Medicine, Fresno, CA 93701, USA
| | - Nicholas D Black
- University of California San Francisco, Fresno Medical Education Program, Department of Emergency Medicine, Fresno, CA 93701, USA
| | - Michael A Darracq
- University of California San Francisco, Fresno Medical Education Program, Division of Medical Toxicology, Fresno, CA 93701, USA
| | - Danielle E Buttke
- National Park Service, Natural Resources Stewardship and Science, Fort Collins, CO 80525, USA
| | | | - Scott E Chew
- Estes Park Emergency Medical Services, Estes Park, CO 80517, USA
| | - William R Lance
- Wyoming Wildlife Veterinary Consulting LLC, Casper, WY 82604, USA
| | | | - Robert Ehrlich
- National Park Service, US Forest Service, Emergency Medical Services, Washington, DC 20240, USA
| | - Elizabeth Hall
- Great Smoky Mountains National Park, Gatlinburg, TN 37738, USA
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Wu F, Darracq MA. Response to "Rising high-acuity emergency care services independently billed by advanced practice providers, 2013 to 2019". Acad Emerg Med 2023; 30:980-981. [PMID: 36871137 DOI: 10.1111/acem.14713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 03/02/2023] [Indexed: 03/06/2023]
Affiliation(s)
- Fred Wu
- Department of Emergency Medicine, University of California, San Francisco-Fresno, Fresno, California, USA
| | - Michael A Darracq
- Department of Emergency Medicine, University of California, San Francisco-Fresno, Fresno, California, USA
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Darracq MA, Thornton SL. A different challenge with Benadryl: adolescent diphenhydramine ingestions reported to National Poison Database System, 2007-2020. Clin Toxicol (Phila) 2022; 60:851-859. [PMID: 35297707 DOI: 10.1080/15563650.2022.2051536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND The US Food and Drug Administration released a warning related to potential adverse effects related to intentional misuse or abuse ingestions of diphenhydramine in September 2020. We sought to evaluate adolescent-aged (13-19 y) diphenhydramine ingestions reported to US poison control centers to characterize these exposures, adverse effects, outcomes, and trends in outcomes and reasons for ingestion. METHODS The US National Poison Database System was queried for all exposures to diphenhydramine between January 1, 2007 and December 31, 2020. RESULTS 47,644 ingestions were included for analysis. An increase in the number of ingestions, percentage of cases due to an intentional reason for ingestion and suspected suicide was observed. More serious outcomes, cardiac complications, seizures, and deaths were more common following intentional ingestions and specifically suspected suicide over misuse or abuse. CONCLUSIONS Adolescent ingestions of diphenhydramine increased between 2007 and 2020. More serious outcomes, intentional reasons, and suspected suicide also increased over the study interval. Suspected suicide was associated with cardiac complications, seizures, coma, and death at higher rates than misuse or abuse. While misuse and abuse remain a concern, public health interventions focusing on the risk that diphenhydramine pose as an agent of suicide attempt may be of higher impact.
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Affiliation(s)
- Michael A Darracq
- Department of Emergency Medicine, Fresno Medical Education Program, University of California, San Francisco, USA.,Division of Medical Toxicology, Fresno Medical Education Program, University of California, San Francisco, USA
| | - Stephen L Thornton
- University of Kansas Medical Center, Kansas Poison Control System, Kansas City, USA
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Wu F, Darracq MA. Comparing Physician Assistant and Nurse Practitioner Practice in U.S. Emergency Departments, 2010-2017. West J Emerg Med 2021; 22:1150-1155. [PMID: 34546892 PMCID: PMC8463052 DOI: 10.5811/westjem.2021.5.51988] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 05/07/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction We sought to compare physician assistant (PA) and nurse practitioner (NP) practice in United States emergency departments (ED) based on ED visits as reported by the National Hospital Ambulatory Medical Care Survey (NHAMCS). Methods We performed a retrospective, secondary analysis of the 2010 to 2017 NHAMCS with analysis of ED visits, patient demographics, and hospital characteristics. Results Between 2010 to 2017, 21.0% (95% confidence interval, [CI] +/−3.1%) of ED visits were seen by either a PA/NP (with and without physician involvement) and 8.6% (+/−2.9%) were seen by PA/NP alone. We identified an increase for NP visits between 2014–2016 and found that PA/NP visits share many of the same characteristics. Conclusion While emergency medicine has predominately been a specialty for PAs, the number of ED visits with NPs has been increasing over the past several years. While there are some differences, PAs/NPs share many similar practice characteristics in the ED.
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Affiliation(s)
- Fred Wu
- University of California, San Francisco, Department of Emergency Medicine, Fresno, California
| | - Michael A Darracq
- University of California, San Francisco, Department of Emergency Medicine, Fresno, California
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Wu F, Darracq MA. Physician assistant and nurse practitioner utilization in U.S. emergency departments, 2010 to 2017. Am J Emerg Med 2020; 38:2060-2064. [PMID: 33142175 DOI: 10.1016/j.ajem.2020.06.032] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 06/08/2020] [Accepted: 06/09/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Physician Assistants (PAs) and Nurse Practitioners (NPs) are widely utilized in United States (US) Emergency Departments(EDs). We sought to characterize ED PA and NP utilization and practice characteristics in US EDs 2010-2017. METHODS A retrospective, secondary analysis of the Center for Disease Control's National Hospital Ambulatory Medical Care Survey was performed. National estimates of ED visits involving PAs/NPs alone (PA/NP), PAs/NPs with physician involvement (PA/NP+), or physician only (PHYS) were analyzed for patient demographics and hospital characteristics. RESULTS Between 2010 and 2017, 1 billion US ED visits occurred. 8.4% (±4.2%) of visits were seen by a PA/NP, and 11.8% (±4.5%) by a PA/NP+; 76.3% (±7.2%) by PHYS. There was an increase in utilization by PA/NP observed in 2016. PA/NP acuity was highest for semi-urgent/nonurgent (53.2%, ±8.6%). PA/NP see the minority of ambulance arrivals [5.4% (±1.2%)] and admit less patients overall [1.6% (±0.7%)]. Less laboratory [53.6% (±10.0%) vs. 67.0% (±6.2%)] and radiographic [38.0% (±7.0%) vs. 51.6% (±4.6%)] studies were performed during PA/NP only vs. PHYS visits. PA/NP visits were most common for patients 25-44 years old (yo) (31.1%, ±5.5%) and 0-15 yo (23.9%, ±4.7%). Most PA/NP visits result in a length of stay (LOS) between 1 and 1.9 h (33.4%, ±5.7%) compared to most PHYS visits resulting in a LOS greater than 3 h (40.3%, ±3%). CONCLUSIONS From 2010 to 2015, PA/NP utilization remained stable until an increase in 2016. There was a decrease in 2017. Various PA/NP patient characteristics are significant compared to PHYS. PHYS continue to see most ED patients.
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Affiliation(s)
- Fred Wu
- Department of Emergency Medicine, University of California San Francisco, Fresno, United States of America.
| | - Michael A Darracq
- Department of Emergency Medicine, University of California San Francisco, Fresno, United States of America
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Darracq MA, Thornton SL. Respiratory depression following medications for opioid use disorder (MOUD)-approved buprenorphine product oral exposures; National Poison Database System 2003–2019. Clin Toxicol (Phila) 2020; 59:303-312. [DOI: 10.1080/15563650.2020.1814318] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Michael A. Darracq
- Department of Emergency Medicine, Division of Medical Toxicology, Fresno Medical Education Program, University of California, San Francisco (UCSF), Fresno, CA, USA
| | - Stephen L. Thornton
- Department of Emergency Medicine, Kansas Poison Control System, University of Kansas Health System, Kansas City, KS, USA
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Darracq MA, Thornton SL. Sustained stimulation? Characteristics of modified release and immediate release stimulant exposures reported to the national poison data system. Clin Toxicol (Phila) 2020; 59:200-207. [PMID: 32609552 DOI: 10.1080/15563650.2020.1787428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE We sought to examine ADHD modified release (MR) and immediate release (IR) stimulant ingestion exposures reported to the National Poison Data System (NPDS) to characterize the nature of the exposures and the outcomes associated with them. METHODS The NPDS was queried for all single-substance exposures to MR and IR ADHD preparations between January 1, 2007 and December 31, 2017. MR and IR preparations were identified by a generic code of "amphetamine and related compounds" or "methylphenidate" and specific product name containing XR, CD, ER, LA, and SR. RESULTS A total of 15,796 MR ingestions and 23,418 IR ingestions were identified and followed to known outcome. The majority of ingestions occurred in male patients and in own residence. More serious outcomes (moderate, major, or death) were more common in adult IR and MR ingestions as compared to pediatric; rates of serious outcome increased with age amongst pediatric ingestions. Unintentional ingestions were more common in both MR and IR pediatric cases while intentional ingestions occurred more frequently in adult cases. Symptoms consistent with a hyperadrenergic state were experienced in adult and pediatric patients for both MR and IR ingestions. Supportive care including benzodiazepine administration was more common in IR than MR ingestions. Decontamination with whole bowel irrigation was infrequent. CONCLUSION Rates of more serious outcome were similar between IR and MR ADHD stimulant ingestions. More serious outcomes were associated with advancing age and intentional ingestions. Similar rates of agitation, tachycardia, and hypertension were experienced by pediatric IR and MR ingestions while more common in adult IR as compared to MR ingestions. Rates of decontamination with whole bowel irrigation were overall low.
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Affiliation(s)
- Michael A Darracq
- University of California, San Francisco (UCSF), Fresno Medical Education Program, Department of Emergency Medicine, Fresno, CA, USA
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Darracq MA. Clinical Utility of Carnett and closed eye sign in emergency department. Am J Emerg Med 2020; 38:2759.e1-2759.e4. [PMID: 32507573 DOI: 10.1016/j.ajem.2020.05.077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 05/21/2020] [Accepted: 05/24/2020] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Carnett's sign (CAR) and Closed Eye sign (CE) have been suggested for use in the emergency department setting in the management of abdominal pain. The present study sought to determine the sensitivity/specificity of CAR and CE for pathological CT findings as a primary outcome and for subsequent hospital admission or surgical intervention as secondary outcomes in a community emergency department setting. METHODS A convenience sample of adults (≥18 y) presenting with acute (<48 h) nontraumatic and non-postoperative abdominal pain determined by treating provider to warrant CT imaging were eligible for enrollment. Treating providers completed a datasheet describing physical examination findings prior to CT imaging. RESULTS 320 patients were enrolled. 245/320 (76.5%) of enrolled patients had findings on CT Imaging. CAR+ was recorded in 145 and CAR- in 175 patients. CE+ was in 187 and CAR- in 133 patients. Sensitivity and specificity of CAR- for hospital admission was 42.2% and 38.9% and for surgery-44.8% and 43.1%. Sensitivity and specificity of CE- for hospital admission was 28% and 51.6% and for surgery-25.9% and 55%. CAR+ patients were more likely to be admitted or undergo surgery as compared to CAR-. CE+ patients were more likely to be admitted or undergo surgery as compared to CAR-. There were no differences in frequency of pathological CT findings between CAR+ and CAR- or CE+ and CE- patients. CONCLUSION CAR and CE are neither sufficiently sensitive nor specific for use in the emergency department setting. CT findings were equally likely in CAR+ and CAR- patients. CT Findings were also equally likely in CE+ and CE- patients.
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Affiliation(s)
- Michael A Darracq
- University of California, San Francisco (UCSF), Fresno Medical Education Program, Department of Emergency Medicine, Division of Medical Toxicology, 155. N. Fresno Street, Fresno, CA 93701, United States of America.
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Wu F, Darracq MA. Physician assistant utilization in U.S. emergency departments; 2010 to 2017. Am J Emerg Med 2020; 42:132-136. [PMID: 32067840 DOI: 10.1016/j.ajem.2020.02.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 02/05/2020] [Accepted: 02/09/2020] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Physician Assistants (PAs) are widely used in United States (US) Emergency Departments (EDs). We sought to characterize ED PA utilization and practice characteristics in US EDs 2010-2017. METHODS A retrospective, secondary analysis of the 2010 to 2017 Center for Disease Control's National Hospital Ambulatory Medical Care Survey (NHAMCS) was performed. National estimates of ED visits involving PAs alone (PA), PAs with physician involvement (PA+), or physician only (PHYS) were analyzed for patient demographics and hospital characteristics. RESULTS Between 2010 and 2017, an estimated 1 billion US ED visits occurred. 5.0% (95% confidence interval [CI] ±2.7%) of visits were seen by a PA, and 8.2% (±2.7%) by a PA+; 76.3% (±7.2%) by PHYS. No linear trends by year were identified in PA or PA+ visits. PA acuity was highest for semi-urgent/nonurgent (56.4%, ±10.7%). PA see the minority of ambulance arrival [5.8% (±1.3)] and admit less patients [1.7% (±0.7%)]. Less laboratory [53.3% (±10.2%) vs. 67.0% (±6.2%)] and radiographic [38.8% (±6.6%) vs. 51.6% (±4.6%) studies were performed during PA vs. PHYS visits. PA visits were most common for patients 25-44 years old (yo) (32.9%, ±6.2%) and 15-24 yo (19.2%, ±3.7%). Most PA visits result in a length of stay (LOS) between 1 and 1.9 h (32.9%, ±6.7%) compared to most PHYS visits resulting in a LOS >3 h (40.3%, ±3%). CONCLUSIONS From 2010 to 2017, no linear trends in US ED PA and PA+ utilization were identified. PHYS continue to see the majority of ED patients.
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Affiliation(s)
- Fred Wu
- Department of Emergency Medicine, University of California San Francisco (UCSF), Fresno, United States of America.
| | - Michael A Darracq
- Department of Emergency Medicine, University of California San Francisco (UCSF), Fresno, United States of America
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Darracq MA, Lee J, Wilson T, Lasoff D, Armenian P. Pharmacist dispensed naloxone: Knowledge, availability, participation and cost in selected California counties. International Journal of Drug Policy 2019; 71:113-117. [PMID: 31301549 DOI: 10.1016/j.drugpo.2019.06.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 03/21/2019] [Accepted: 06/05/2019] [Indexed: 11/24/2022]
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Thornton SL, Darracq MA, Gugelmann HM, Armenian P. Surface internet marketplace presence and availability of NPS sold as research chemicals: a snapshot study. Toxicology Communications 2019. [DOI: 10.1080/24734306.2019.1648067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Affiliation(s)
- Stephen L. Thornton
- Department of Emergency Medicine, Kansas Poison Control System, University of Kansas Medical Center, Kansas City, KS, USA
| | - Michael A. Darracq
- Department of Emergency Medicine, University of California San Francisco-Fresno, Fresno, CA, USA
| | - Hallam M. Gugelmann
- Department of Emergency Medicine, California Pacific Medical Center St. Luke’s Campus, and California Poison Control System, San Francisco Division, San Francisco, CA, USA
| | - Patil Armenian
- Department of Emergency Medicine, University of California San Francisco-Fresno, Fresno, CA, USA
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Riccoboni ST, Darracq MA. Does the U Stand for Useless? The Urine Drug Screen and Emergency Department Psychiatric Patients. J Emerg Med 2018; 54:500-506. [DOI: 10.1016/j.jemermed.2017.12.054] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 12/15/2017] [Accepted: 12/26/2017] [Indexed: 10/17/2022]
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Affiliation(s)
- Michael A Darracq
- Department of Emergency Medicine, Division of Medical Toxicology, University of California, San Francisco (UCSF) Fresno Medical Education Program, United States.
| | - Patil Armenian
- Department of Emergency Medicine, Division of Medical Toxicology, University of California, San Francisco (UCSF) Fresno Medical Education Program, United States
| | - James Comes
- Department of Emergency Medicine, University of California, San Francisco (UCSF) Fresno Medical Education Program, United States
| | - Stephen Thornton
- Department of Emergency Medicine, University of Kansas Medical Center, Kansas Poison Control System, United States
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Burger J, Capobianco M, Lovern R, Boche B, Ross E, Darracq MA, McLay R. A Double-Blinded, Randomized, Placebo-Controlled Sub-Dissociative Dose Ketamine Pilot Study in the Treatment of Acute Depression and Suicidality in a Military Emergency Department Setting. Mil Med 2017; 181:1195-1199. [PMID: 27753551 DOI: 10.7205/milmed-d-15-00431] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Rates of completed suicide in the military have increased. Options are limited for acute relief of depression and suicidal ideation. Traditional treatments' effects take weeks to months. A novel, rapid, therapeutic target has emerged with the N-methyl-D-aspartate antagonist ketamine. Previous studies suggest that a single dose of intravenous (IV) ketamine rapidly alleviates depression and suicidality. METHODS In this proof of concept study, an active duty convenience sample population presenting to the emergency department (ED) meeting criteria for inpatient psychiatric admission as a result of depression and suicidal thinking were randomized to receive either a subdissociative dose (0.2 mg/kg) of IV ketamine or equivalent volume of normal saline (placebo). Subjects were evaluated for symptoms throughout a 4-hour ED course, at hospital discharge, and 2 weeks postdischarge. RESULTS Methodological problems limited analyzable data to 10 subjects. Two of three who received ketamine experienced dramatic decreases in suicidality and hopelessness within 40 minutes. No such improvements were seen in any of seven controls over the 4-hour observation in the ED. At discharge from the hospital, there was no clinically significant difference. No subjects described adverse symptoms. CONCLUSION Despite methodology difficulties noted in this pilot study, there was statistical improvement in intervention group versus controls.
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Affiliation(s)
- John Burger
- Department of Mental Health, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134
| | - Marc Capobianco
- Department of Mental Health, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134
| | - Robert Lovern
- Department of Mental Health, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134
| | - Ben Boche
- Department of Mental Health, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134
| | - Elliot Ross
- Department of Emergency Medicine, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134
| | - Michael A Darracq
- Department of Emergency Medicine, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134
| | - Robert McLay
- Department of Mental Health, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134
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Ramirez R, Stalcup P, Croft B, Darracq MA. Haloperidol undermining gastroparesis symptoms (HUGS) in the emergency department. Am J Emerg Med 2017; 35:1118-1120. [PMID: 28320545 DOI: 10.1016/j.ajem.2017.03.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 03/10/2017] [Accepted: 03/10/2017] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Gastroparesis associated nausea, vomiting & abdominal pain (GP N/V/AP) are common presentations to the emergency department (ED). Treatment is often limited to antiemetic, prokinetic, opioid, & nonopioid agents. Haloperidol (HP) has been shown to have analgesic & antiemetic properties. We sought to evaluate HP in the ED as an alternative treatment of GP N/V/AP. METHODS Using an electronic medical record, 52 patients who presented to the ED w/GP N/V/AP secondary to diabetes mellitus and were treated w/HP were identified. Patients who received HP were compared to themselves w/the most recent previous encounter in which HP was not administered. ED length of stay (LOS), additional antiemetics/prokinetics administered, hospital LOS, and morphine equivalent doses of analgesia (ME) from each visit were recorded. Descriptive statistics, categorical (Chi Square Test or Z-Test for proportion) and continuous (Wilcoxon Signed Rank Test) comparisons were calculated. Statistical significance was considered for two tail p-values less than 0.05. RESULTS A statistically significant reduction in ME (Median 6.75 [IQR 7.93] v 10.75 [IQR12]: p=0.001) and reduced admissions for GP (5/52 v 14/52: p=0.02) when HP was administered was observed. There were no statistically significant differences in ED or hospital LOS, and additional antiemetics administered between encounters in which HP was administered and not administered. No complications were identified in patients who received HP. CONCLUSIONS The rate of admission and ME was found to be significantly reduced in patients with GP secondary to diabetes mellitus who received HP. HP may represent an appropriate, effective, and safe alternative to traditional analgesia and antiemetic therapy in the ED management of GP associated N/V/AP.
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Affiliation(s)
- Rene Ramirez
- UCSF-Fresno, Department of Emergency Medicine, Fresno, CA, USA; Community Regional Medical Center, Fresno, CA, USA.
| | - Philip Stalcup
- UCSF-Fresno, Department of Emergency Medicine, Fresno, CA, USA; Community Regional Medical Center, Fresno, CA, USA
| | - Brandon Croft
- UCSF-Fresno, Department of Emergency Medicine, Fresno, CA, USA; Community Regional Medical Center, Fresno, CA, USA
| | - Michael A Darracq
- UCSF-Fresno, Department of Emergency Medicine, Fresno, CA, USA; Community Regional Medical Center, Fresno, CA, USA
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Darracq MA, Thornton SL, Minns AB, Gerona RR. A Case of 3,4-Dimethoxyamphetamine (3,4-DMA) and 3,4-Methylenedioxymethamphetamine (MDMA) Toxicity with Possible Metabolic Interaction. J Psychoactive Drugs 2016; 48:351-354. [PMID: 27636207 DOI: 10.1080/02791072.2016.1225324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
We present a case of "ecstasy" ingestion revealing 3,4-methylenedioxymethamphetamine (MDMA) and 3,4-dimethoxyamphetamine (3,4-DMA) and absence of cytochrome P450 (CYP)-2D6 MDMA metabolites. CASE REPORT A 19-year-old presented following a seizure. Initial vital signs were normal. Laboratories were normal with the exception of sodium 127 mEq/L and urine drugs of abuse screen positive for amphetamines. Twelve hours later, serum sodium was 114 mEq/L and a second seizure occurred. After receiving hypertonic saline (3%), the patient had improvement in mental status and admitted to taking "ecstasy" at a rave prior to her initial presentation. Liquid chromatography-time-of-flight mass spectrometry (LC-TOF/MS) of serum and urine revealed MDMA, 3,4-DMA, and the CYP-2B6 MDMA metabolites 3,4-methylendioxyamphetamine (MDA) and 4-hydroxy-3-methoxyamphetamine (HMA). The CYP2D6 metabolites of MDMA, 3,4-dihydromethamphetamine (HHMA) and 4-hydroxy-3-methoxymethamphetamine (HMMA), were detected at very low levels. CONCLUSION This case highlights the polypharmacy which may exist among users of psychoactive illicit substances and demonstrates that concurrent use of MDMA and 3,4-DMA may predispose patients to severe toxicity. Toxicologists and other healthcare providers should be aware of this potential toxicity.
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Affiliation(s)
- Michael A Darracq
- a Assistant Professor, Fresno Medical Education Program, Department of Emergency Medicine, Division of Medical Toxicology , University of California San Francisco , Fresno , CA , USA
| | - Stephen L Thornton
- b Assistant Professor, Department of Emergency Medicine, Kansas Poison Control System , University of Kansas Medical Center , Kansas City , KS , USA
| | - Alicia B Minns
- c Assistant Professor, Department of Emergency Medicine, Division of Toxicology , University of California San Diego , San Diego , CA , USA
| | - Roy R Gerona
- d Assistant Professor, Department of Laboratory Medicine , University of California San Francisco , San Francisco , CA , USA
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Darracq MA, Cantrell FL, Klauk B, Thornton SL. A chance to cut is not always a chance to cure- fasciotomy in the treatment of rattlesnake envenomation: A retrospective poison center study. Toxicon 2015; 101:23-6. [DOI: 10.1016/j.toxicon.2015.04.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Revised: 04/20/2015] [Accepted: 04/28/2015] [Indexed: 10/23/2022]
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Deaton T, Auten JD, Darracq MA. Nebulized fentanyl vs intravenous morphine for ED patients with acute abdominal pain: a randomized double-blinded, placebo-controlled clinical trial. Am J Emerg Med 2015; 33:791-5. [DOI: 10.1016/j.ajem.2015.03.046] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Revised: 02/27/2015] [Accepted: 03/19/2015] [Indexed: 11/29/2022] Open
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Ross EM, Darracq MA. Complementary and Alternative Medicine Practices in Military Personnel and Families Presenting to a Military Emergency Department. Mil Med 2015; 180:350-4. [DOI: 10.7205/milmed-d-14-00304] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Darracq MA, Young M. Novel anticoagulants should NOT be recommended for high-risk activity. Wilderness Environ Med 2014; 25:359-60. [PMID: 24731831 DOI: 10.1016/j.wem.2014.01.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Accepted: 01/21/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Michael A Darracq
- UCSF Fresno Medical Education Program, Department of Emergency Medicine, Division of Medical Toxicology and Division of Wilderness Medicine, Fresno, CA
| | - Megann Young
- UCSF Fresno Medical Education Program, Department of Emergency Medicine, Division of Wilderness Medicine, Fresno, CA
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Zanoni S, Carstairs S, Darracq MA. Altered mental status due to pruno intoxication. J Emerg Med 2014; 46:767-8. [PMID: 24680101 DOI: 10.1016/j.jemermed.2013.11.125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Revised: 11/07/2013] [Accepted: 11/27/2013] [Indexed: 11/15/2022]
Abstract
BACKGROUND The diagnosis of alcohol intoxication might not be considered in patients coming from locations where access to alcohol is severely restricted or not permitted. OBJECTIVE We present a case of alcohol intoxication in a patient presenting from a military prison. The patient ingested an alcoholic beverage made in his prison cell with produce stolen from the prison cafeteria. We also discuss potential complications of "prison-brewed" alcoholic beverages. CASE REPORT A 22-year-old male presented to the emergency department after being found in his cell with a depressed level of consciousness and next to a mouthwash bottle filled with a foul-smelling liquid. Physical examination revealed a heart rate of 111 beats/min, a Glasgow Coma Scale score of 11, no signs of injury or track marks on the skin, and intermittent agitation alternating with somnolence. Laboratory evaluation was significant for a serum ethanol level of 279 mg/dL. After a period of observation, mental status returned to normal and the patient admitted to making "pruno." CONCLUSIONS Alcohol intoxication might be unexpected or not considered in patients that should have no access to common sources of ethanol. Awareness of methods of novel fermentation, even in incarcerated individuals, can assist in the differential diagnosis of patients presenting with altered mental status.
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Affiliation(s)
- Stephen Zanoni
- Department of Emergency Medicine, Navy Medical Center San Diego, San Diego, California
| | - Shaun Carstairs
- Department of Emergency Medicine, Navy Medical Center San Diego, San Diego, California
| | - Michael A Darracq
- Division of Medical Toxicology, Department of Emergency Medicine, University of California, San Francisco, Fresno, California
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Lo JCY, Darracq MA, Clark RF. A review of methylene blue treatment for cardiovascular collapse. J Emerg Med 2014; 46:670-9. [PMID: 24508113 DOI: 10.1016/j.jemermed.2013.08.102] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2012] [Revised: 05/07/2013] [Accepted: 08/18/2013] [Indexed: 11/17/2022]
Abstract
BACKGROUND Historically, methylene blue (MB) has been used for multiple purposes, including as an antidote for toxin-induced and hereditary methemoglobinemia, ifosfamide-induced encephalopathy, and ackee fruit and cyanide poisoning; as an aniline dye derivative, antimalarial agent, and antidepressant. DISCUSSION Most recently, the use of MB has been advocated as a potential adjunct in the treatment of shock states. Our article reviews the role of MB in septic shock, anaphylactic shock, and toxin-induced shock. MB is proposed to increase blood pressure in these shock states by interfering with guanylate cyclase activity, and preventing cyclic guanosine monophosphate production and vasodilatation. SUMMARY MB may be an adjunct in the treatment of septic shock, anaphylactic shock, and toxin-induced shock.
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Affiliation(s)
- Jean C Y Lo
- Department of Toxicology, University of California, San Diego, San Diego, California
| | - Michael A Darracq
- Department of Toxicology, University of California, San Diego, San Diego, California
| | - Richard F Clark
- Department of Toxicology, University of California, San Diego, San Diego, California
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Darracq MA, Ghafouri N, Pesce A, Cantrell FL. Hand sanitizer intoxication following a crude extraction method. Am J Drug Alcohol Abuse 2013; 39:217-8. [PMID: 23721538 DOI: 10.3109/00952990.2013.773335] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Zanoni S, Siefert JA, Darracq MA. Atrial fibrillation with rapid ventricular response resulting from low-voltage electrical injury. J Emerg Med 2013; 45:e149-51. [PMID: 23937813 DOI: 10.1016/j.jemermed.2013.05.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Revised: 03/08/2013] [Accepted: 05/01/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Cardiac dysrhythmias after electrical injury have been reported previously, however, atrial fibrillation after low-voltage electrical injury is extremely rare. We present a case of atrial fibrillation with rapid ventricular response resulting from a low-voltage electrical injury. CASE REPORT A 24-year-old active duty Navy sailor presented to the emergency department after an electrical shock from a 440-V furnace. He experienced severe pain in both hands and a racing sensation in his chest. He denied other symptoms. An electrocardiogram was performed demonstrating atrial fibrillation with a rapid ventricular response (132 beats/min). After analgesia and sedation, synchronized cardioversion (100 J) was performed with complete resolution of cardiac symptoms and restoration of normal sinus rhythm (75 beats/min). Cutaneous wounds were bandaged and the patient was discharged with cardiology follow-up. At follow-up, the patient reported no symptoms and an echocardiogram revealed no structural abnormalities. CONCLUSIONS Atrial fibrillation in the setting of electrical injury is rarely reported in the published medical literature. In patients without history suggestive of cardiac structural abnormalities, synchronized cardioversion is a potential option for restoration of normal sinus rhythm and resolution of symptoms after electrical injury-induced atrial fibrillation with rapid ventricular response.
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Affiliation(s)
- Stephen Zanoni
- Department of Emergency Medicine, Navy Medical Center San Diego, San Diego, California
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Darracq MA, Clark RF, Jacoby I, Vilke GM, DeMers G, Cantrell FL. Disaster preparedness of poison control centers in the USA: a 15-year follow-up study. J Med Toxicol 2013; 10:19-25. [PMID: 23842905 DOI: 10.1007/s13181-013-0315-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
There is limited published literature on the extent to which United States (US) Poison Control Centers (PCCs) are prepared for responding to disasters. We describe PCCs' disaster preparedness activities and compare and contrast these results to those previously reported in the medical literature. We also describe the extent to which PCCs are engaged in disaster and terrorism preparedness planning and other public health roles such as surveillance. An electronic questionnaire was sent via email to the managing directors of the 57 member PCCs of the American Association of Poison Control Centers. Collected data included the population served and number of calls received, extent of disaster preparedness including the presence of a written disaster plan and elements included in that plan, the presence and nature of regular disaster drills, experience with disaster including periods of inability to operate, involvement in terrorism and disaster preparedness/response policy development, and public health surveillance of US PCCs. Descriptive statistics were performed on collected data. Comparisons with the results from a previously published survey were performed. A response was obtained from 40/57 (70 %) PCCs. Each PCC serves a larger population (p < 0.0001) and receives more calls per year (p = 0.0009) than the previous descriptions of PCC preparedness. More centers report the presence of a written disaster plan (p < 0.0001), backup by another center (p < 0.0001), regular disaster drills (p < 0.0001), and comfort with ability to operate in a disaster (p < 0.0001) than previously described. PCCs are involved in disaster (34/40, 85 %) and terrorism (29/40, 73 %) preparedness at the local, state, or federal levels. PCCs (36/40, 90 %) are also involved in public health functions (illness surveillance or answering "after hours" public health calls). Despite an increase in calls received and population served per center as compared to previous descriptions, more PCCs report the presence of a written disaster plan, backup by another center, regular disaster drills, and comfort in ability to operate in a disaster. PCCs are actively involved in terrorism and disaster preparedness and response planning and traditional public health responsibilities such as surveillance.
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Affiliation(s)
- Michael A Darracq
- Department of Emergency Medicine, University of California, San Diego, San Diego, CA, USA,
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Darracq MA, Matteucci MJ. Other causes of methemoglobinemia in pediatric patients and potential explanation for ibuprofen-induced methemoglobinemia. In response to "toxic methemoglobinemia due to ibuprofen: report of a pediatric case" by Khemiri et al. J Emerg Med 2013; 44:989-990. [PMID: 23466025 DOI: 10.1016/j.jemermed.2011.03.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2010] [Accepted: 03/16/2011] [Indexed: 06/01/2023]
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Darracq MA, Rentmeester LL, Clark RF, Tomaszewski CA, Schneir AB, Cantrell FL. Cost of hemodialysis versus fomepizole-only for treatment of ethylene glycol intoxication. Clin Toxicol (Phila) 2013; 51:188. [PMID: 23356815 DOI: 10.3109/15563650.2013.766750] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Darracq MA, Ly BT. Gastric aspirate fluorescence in ethylene glycol poisoning. J Emerg Med 2012; 43:e457-e458. [PMID: 22975284 DOI: 10.1016/j.jemermed.2012.07.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2012] [Revised: 03/06/2012] [Accepted: 07/01/2012] [Indexed: 06/01/2023]
Affiliation(s)
- Michael A Darracq
- Department of Emergency Medicine, Division of Medical Toxicology, University of California, San Diego, San Diego, California 92103-1911, USA
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Ward NT, Darracq MA, Tomaszewski C, Clark RF. Evidence-based treatment of jellyfish stings in North America and Hawaii. Ann Emerg Med 2012; 60:399-414. [PMID: 22677532 DOI: 10.1016/j.annemergmed.2012.04.010] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2011] [Revised: 03/28/2012] [Accepted: 04/09/2012] [Indexed: 01/22/2023]
Abstract
We performed a systematic review of the evidence supporting various treatments for envenomation by jellyfish (cnidarian) and related organisms in North America and Hawaii. Our review produced 19 pertinent primary articles. Current research demonstrates variable response to treatment, often with conflicting results according to species studied, which contributes to considerable confusion about what treatment is warranted and efficacious. Our review suggests that vinegar causes pain exacerbation or nematocyst discharge in the majority of species. Hot water and topical lidocaine appear more widely beneficial in improving pain symptoms and are preferentially recommended. Unfortunately, they may be difficult to obtain at the site of envenomation, such as the beach or diving sites. In these instances, removing the nematocysts and washing the area with saltwater may be considered. If the envenomation is thought to be due to the bluebottle (Physalia), vinegar may be beneficial.
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Affiliation(s)
- Nicholas T Ward
- Department of Emergency Medicine, Division of Medical Toxicology, UCSD Medical Center, University of California, San Diego, San Diego, CA, USA.
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Darracq MA. Comment: Neuroleptic Malignant Syndrome Versus Serotonin Syndrome: The Search for a Diagnostic Tool. Ann Pharmacother 2012; 46:611-2; author reply 613. [DOI: 10.1345/aph.1p787a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Michael A Darracq
- Clinical Fellow Department of Emergency Medicine/Division of Medical Toxicology University of California, San Diego San Diego, CA
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Darracq MA. Images in emergency medicine: left atrial myxoma. West J Emerg Med 2008; 9:125. [PMID: 19561723 PMCID: PMC2672241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2007] [Revised: 03/17/2008] [Accepted: 03/18/2008] [Indexed: 11/02/2022] Open
Affiliation(s)
- Michael A. Darracq
- Address for Correspondence: Michael A. Darracq MD, Department of Emergency Medicine, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134.
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Affiliation(s)
- Michael A Darracq
- Department of Emergency Medicine, University of California, Davis Medical Center, and California Poison Control System, Sacramento, CA, USA
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Conner JM, Darracq MA, Roberts J, Tuszynski MH. Nontropic actions of neurotrophins: subcortical nerve growth factor gene delivery reverses age-related degeneration of primate cortical cholinergic innervation. Proc Natl Acad Sci U S A 2001; 98:1941-6. [PMID: 11172055 PMCID: PMC29361 DOI: 10.1073/pnas.98.4.1941] [Citation(s) in RCA: 91] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2000] [Indexed: 11/18/2022] Open
Abstract
Normal aging is associated with a significant reduction in cognitive function across primate species. However, the structural and molecular basis for this age-related decline in neural function has yet to be defined clearly. Extensive cell loss does not occur as a consequence of normal aging in human and nonhuman primate species. More recent studies have demonstrated significant reductions in functional neuronal markers in subcortical brain regions in primates as a consequence of aging, including dopaminergic and cholinergic systems, although corresponding losses in cortical innervation from these neurons have not been investigated. In the present study, we report that aging is associated with a significant 25% reduction in cortical innervation by cholinergic systems in rhesus monkeys (P < 0.001). Further, these age-related reductions are ameliorated by cellular delivery of human nerve growth factor to cholinergic somata in the basal forebrain, restoring levels of cholinergic innervation in the cortex to those of young monkeys (P = 0.89). Thus, (i) aging is associated with a significant reduction in cortical cholinergic innervation; (ii) this reduction is reversible by growth-factor delivery; and (iii) growth factors can remodel axonal terminal fields at a distance, representing a nontropic action of growth factors in modulating adult neuronal structure and function (i.e., administration of growth factors to cholinergic somata significantly increases axon density in terminal fields). These findings are relevant to potential clinical uses of growth factors to treat neurological disorders.
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Affiliation(s)
- J M Conner
- Department of Neurosciences, University of California at San Diego, La Jolla, CA 92093-0626, USA
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