Cottonmouth snake bites reported to the ToxIC North American snakebite registry 2013-2017.

Introduction: The majority of venomous snake exposures in the United States are due to snakes from the subfamily Crotalinae (pit vipers). There are three types of US pit vipers: rattlesnakes (Crotalus and Sisturus spp.) copperheads (Agkistrodon contortrix), and cottonmouths (Agkistrodon piscivorus) also known as water moccasins. Cottonmouth bites are reported less frequently than other pit viper envenomations, and data on cottonmouth envenomation are limited. Our objective was to describe the epidemiology, clinical manifestations, and management of cottonmouth envenomations using prospective data reported to the Toxicology Investigators Consortium's (ToxIC) North American Snakebite Registry (NASBR)Methods: Cottonmouth envenomation cases reported to NASBR for the period from January 1, 2013, through December 31, 2017 were reviewed. Variables collected included patient demographics, bite location, clinical manifestations, and management.Results: Thirty-one cottonmouth envenomations were reported. Most bites occurred in children aged 7-12 (39%). Most bites involved the lower extremity (72%). Intentional interaction with the snake occurred in three cases (10%). Swelling was the most reported clinical effect and occurred in all patients. Gastrointestinal symptoms were reported in 19% of patients, and 19% developed coagulopathy. Antivenom treatment was used in 84% of patients. Nineteen patients (61%) required hospital stays of >24 hours.Discussion: Our study represents the first systematic prospective data collection on cottonmouth bites. Our data demonstrate that cottonmouth envenomations cause primarily local effects and, occasionally, systemic toxicity. Our study also demonstrates that antivenom is often indicated for these envenomations per published guidelines and recommendations.Conclusions: Cottonmouth envenomations are relatively infrequent. However, they can cause significant local and systemic toxicity. Most cottonmouth envenomations in this series were treated with antivenom and were hospitalized beyond 24 hours.

Two cases of intoxication with new synthetic opioid, U-47700.

BACKGROUND: Novel substances often referred to as "designer drugs" have emerged as drugs of abuse, and recognition of these is difficult as routine blood and urine screening tests do not detect these agents. U-47700 is a synthetic selective µ-opioid agonist that can be bought online for as little as $40 per gram. We report two patients presenting after insufflation of U-47700, with subsequent confirmation of this substance in urine samples. CASE DETAILS: A 26-year-old man and 24-year-old woman insufflated a substance they believed to be "synthetic cocaine." The man was found down with cyanosis and agonal respirations. He was intubated and taken to hospital where he recovered well with supportive care. The woman presented with anxiety, tremors and drowsiness and was admitted for observation. Urine samples from both patients were analyzed using GC/MS/MS and LC/QToF, and U-47700 was isolated in both cases. No other opioids were detected. DISCUSSION: These cases are concerning because U-47700 is a relatively new agent that is easy to obtain over the internet and has the potential to cause significant morbidity and mortality.

Elder abuse: a review.

Elder abuse exists in many forms: physical, emotional, financial, and sexual; neglect; and self-neglect. As many as 2.5 million older people are abused each year, and the number of cases will likely increase as this population grows. Elder abuse receives less attention than other forms of domestic violence, and fewer than 10% of cases are reported. Although all states have legislation addressing elder abuse, financial support for evaluation and protective services is lacking. Most states have mandatory reporting; however, it may infringe on the autonomy of competent geriatric individuals. Physicians infrequently report elder abuse because they are not familiar with reporting laws, fear offending patients, are concerned with time limitations, and believe they do not have appropriate evaluation skills. Victims often have low self-esteem, blame themselves for the abuse, and do not want to admit their vulnerabilities or betray their families. The "caregiver stress hypothesis," which suggests abuse stems from caregiver stress and resentment resulting from chronic care of dependent geriatric patients, is a misconception. Abuse is actually better correlated with the emotional and financial dependence of the caregivers on the geriatric victims. Older patients are most commonly abused by the people with whom they live. Older men and women have similar per capita abuse rates. Assessment and management should be supportive without assigning blame and should focus on both the patient and the caregiver. Patients in immediate danger should be hospitalized or placed in emergency shelters. Suspected abuse should be reported directly to the appropriate state agency, which can provide a thorough long-term assessment.