Emergence of fentanyl-related deaths in Travis County, Texas and surrounding areas: A retrospective review of postmortem fentanyl-related drug toxicities from 2020 to 2022.

The opioid epidemic has affected the United States (US) for decades with fentanyl and its analogs accounting for a recent surge in morbidity and mortality. Currently, there is a relative lack of information characterizing fentanyl-related fatalities specifically in the Southern US. A retrospective study was conducted to examine all postmortem fentanyl-related drug toxicities in Travis County, Texas, encompassing Austin (one of the fastest-growing cities in the US), from 2020 to 2022. Fentanyl contributed to 2.6% and 12.2% of deaths submitted for toxicology between 2020 and 2022, respectively, representing a 375% increase in fentanyl-related deaths over this 3-year period (n = 517). Fentanyl-related fatalities primarily occurred in males in their mid-30s. Fentanyl and norfentanyl concentrations ranged from 0.58 to 320 ng/mL and 0.53 to 140 ng/mL with mean (median) concentrations of 17.2 ± 25.0 (11.0) and 5.6 ± 10.9 (2.9) ng/mL, respectively. Polydrug use was present in 88% of cases, with methamphetamine (or other amphetamines) (25%), benzodiazepines (21%), and cocaine (17%) representing the most frequently identified concurrent substances. Co-positivity rates of various drugs and drug classes widely varied over time. Scene investigations reported illicit powder(s) (n = 141) and/or illicit pill(s) (n = 154) in 48% (n = 247) of fentanyl-related deaths. Illicit oxycodone (44%, n = 67) and illicit "Xanax" (38%, n = 59) pills were frequently reported on scene; however, toxicology only identified oxycodone and alprazolam in 2 and 24 of these cases, respectively. The results of this study provide a better understanding of the fentanyl epidemic in this region creating an opportunity to promote increased awareness, shift focus to harm reduction, and aid in minimizing public health risks.

Refractive Outcomes Following Trifocal Intraocular Lens Implantation in Post-Myopic LASIK and PRK Eyes.

Purpose: To assess refractive outcomes of a trifocal intraocular lens (IOL) in post-myopic laser refractive surgery eyes. Methods: This was a retrospective chart review of 35 eyes (21 patients), with history of laser refractive surgery, who were implanted with a trifocal IOL. Surgeon's standard procedure included femtosecond laser (FLACS), digital registration, and intraoperative aberrometry (IA). The primary outcome measure was absolute prediction error. Secondary measures were refractive outcomes, postoperative residual astigmatism (PRA), monocular uncorrected visual acuity at distance (UDVA; 4m), intermediate (UIVA; 60cm), and near (UNVA; 40cm), and monocular best-corrected visual acuity at distance (BCVA; 4m). Results: At 3 months postoperatively, 71% and 68% of eyes had absolute prediction error 0.5 D or less with IA and preoperative planning respectively, which was not statistically significant (p > 0.05). The PRA was 0.5 D or less in 91% of eyes with IA and 56% of eyes with preoperative planning. The PRA differences between IA and preoperative planning were statistically significant (p < 0.002). The percentage of eyes 20/20 or better for monocular UCVA, BCVA, UIVA, and UNVA was 29%, 77%, 78%, and 66%, respectively. Absolute prediction error 0.5 D or less was significantly higher in post-LASIK eyes versus post-PRK eyes (p < 0.003), at 85% and 56% of eyes, respectively. Conclusion: Implantation with a trifocal IOL can provide acceptable refractive and visual outcomes with minimal residual astigmatism in post-myopic LASIK and PRK eyes.

Clinical Outcomes of Monofocal Toric IOLs Using Digital Tracking and Intraoperative Aberrometry.

PURPOSE: To evaluate clinical outcomes of a toric IOL using digital tracking (DT) and intraoperative aberrometry (IA). METHODS: This was a retrospective, single surgeon study examining 151 eyes of 106 patients. Inclusion criteria were subjects who presented with visually significant cataracts (or as a candidate for clear lens extraction) and were implanted with a toric intraocular lens. Spherical equivalent prediction errors for IA and preoperative planning were calculated and compared. Preoperative and postoperative refractive data and monocular uncorrected distance visual acuity (UDVA) and corrected distance visual acuity (CDVA) were also collected at 3 months postoperatively. RESULTS: Postoperative actual residual refractive astigmatism with IA was 0.50 D or less in 140 eyes (92.8%) and was 0.50 D or less in 88 eyes (58.3%) with back-calculations based on preoperative planning. The absolute spherical equivalent prediction error was 0.50 D or less in 135 eyes (89.4%) for IA compared to 123 eyes (85.4%) for preoperative planning. Postoperative monocular UDVA was 0.10 logMAR or better in 124 eyes (82.1%) and 0.00 logMAR or better in 90 eyes (59.6%). Postoperative CDVA was 0.10 logMAR or better in 147 eyes (97.4%) and 134 eyes (88.7%) were 0.00 logMAR or better. CONCLUSION: The results demonstrate that toric implantation with DT and IA can provide excellent refractive and visual outcomes.

Multiple Drug-Toxicity Involving Novel Psychoactive Substances, 3-Fluorophenmetrazine and U-47700.

3-Fluorophenmetrazine (3-FPM) is a stimulant-like novel psychoactive substance (NPS) and fluorinated analog of phenmetrazine that has recently appeared on the recreational drug market, with limited published information. Likewise, the synthetic opioid U-47700 has gained popularity among recreational drug users and is frequently detected in postmortem casework. We present the case history, autopsy and toxicological findings of a fatality involving the designer drugs 3-FPM and U-47700 for the first time in the literature. A sensitive and specific liquid chromatography-tandem mass spectrometry method was developed and validated for the quantification of 3-FPM in whole blood, with a 0.001-0.100 mg/L analytical range. The method met the requirements for acceptable linearity, bias and precision. 3-FPM was detected along with U-47700 and other drugs including amitriptyline, nortriptyline, methamphetamine, amphetamine, diazepam, nordiazepam, temazepam, and the designer benzodiazepines flubromazolam and delorazepam. 3-FPM was quantified in the decedent's peripheral (femoral) and central (aortic) blood at 2.4 and 2.6 mg/L, respectively. These concentrations are similar to reported concentrations in non-fatal intoxications. U-47700 was present in peripheral blood at a semi-quantitative concentration of 0.36 mg/L, consistent with reported U-47700 postmortem concentrations. The cause of death was considered multiple drug-toxicity (3-FPM, U-47700, amitriptyline, methamphetamine, diazepam, temazepam, flubromazolam and delorazepam) and the manner of death ruled an accident. This case illustrates the dangers of polysubstance use and discusses the potential overlap between recreational and fatal concentrations for some NPS.

Silicone allergies and the eye: fact or fiction?

OBJECTIVE: The purpose of this manuscript was to review the evidence concerning the role of an allergic reaction to silicone as the basis for the reported increase in contact lens-associated infiltrates in wearers of silicone hydrogel contact lenses. METHODS: A literature review was undertaken to investigate the antigenic properties of silicone and the causes of contact lens-associated inflammatory reactions. RESULTS: Immune cells cannot interact with silicone directly but can interact with antigens on these lenses. These antigens could be due to tear film deposits, microbial contamination, or components of care systems used with these lenses. CONCLUSIONS: Inflammatory reactions associated with silicone hydrogel contact lens wear are not caused by an allergic reaction to silicone alone.

Contact lens cases: the missing link in contact lens safety?

PURPOSE: To summarize a variety of issues associated with contact lens case contamination and discuss appropriate methods that can limit this. METHODS: A literature review was undertaken investigating the major factors associated with case contamination, with specific reference to the major pathogens associated with contamination, the role of bacterial biofilms, and methods that can limit contamination. RESULTS: The use of antimicrobial cases, regular case cleaning and case replacement, avoidance of topping up solutions, and not using tap water to rinse cases all appear to be important in avoidance of significant case contamination. CONCLUSIONS: Contact lens case contamination is a significant public health concern and may contribute significantly to the development of microbial keratitis in contact lens wearers. Patients should be reminded that they must clean and disinfect their lens cases daily, should avoid the use of tap water for rinsing them, must not top up their solutions, must take into careful consideration where and how the cases are stored during the time that lenses are being worn and that they must be replaced regularly. The adoption of these methods will substantially reduce the levels of contamination of cases with pathogenic microbes.

Three deaths associated with use of Xyrem.

Fatalities resulting from popular use of gamma hydroxybutyrate (GHB) have previously been reported. We report three deaths associated with use of Xyrem (sodium oxybate), a pharmaceutical preparation of GHB initially approved for treatment of narcolepsy with cataplexy. One death appears associated with Xyrem abuse, with extremely high postmortem blood GHB levels documented. Although postmortem blood GHB levels in two other deaths are consistent with therapeutic levels, cause and effect cannot be established. We discuss these cases and factors which may have exerted contributory respiratory depressant effects, singly or in combination, including concurrent use of sedative hypnotics, obstructive sleep apnea, and obesity.