e-Health for COVID-19 Epidemic: The Arizona Poison and Drug Information Center Experience.

Background: A significant challenge of the COVID-19 epidemic was the dissemination of accurate and timely information to the public, health care providers, and first responders. We describe the expansion of the Arizona Poison and Drug Information Center (APDIC) to fill such a need for residents of Arizona. Methodology: The original mission of the APDIC was recognition and management of chemical exposure, poisoning, envenomation, and drug-related medical problems. In response to COVID-19, APDIC expanded its personnel and facilities to accommodate telephone calls and teleconsults regarding COVID-19. Thirteen different topics dealing with COVID-19 were addressed and tracked and included: testing information, isolation, prevention, personal protective equipment, travel, vaccines, therapies, antibody testing, contact tracing, exposure to the virus and what to do in businesses, at work or at school regarding isolation and quarantine. Results: Responding to the public health needs, APDIC accepted >320,000 telephone calls and completed 48,346 teleconsults from March 3, 2020 to March 3, 2021. This represented a 15-fold increase in calls and twice the number of consults over 2019. Upon release of the vaccine, calls increased sharply with >7,000 calls in 1 day (February 7, 2021). Conclusion: In conclusion, the APDIC, rapidly expanded to address urgent public health information needs surrounding COVID-19 while still accomplishing its founding mission.

Scorpion Stings and Antivenom Use in Arizona.

BACKGROUND: Arizona's rugged desert landscape harbors many venomous animals, including a small nocturnal scorpion, Centruroides sculpturatus, whose venom can cause severe neuromotor disturbance. An effective antivenom is available at selected health care facilities in the state. METHODS: We analyzed 4398 calls of scorpion stings to the Arizona Poison and Drug Information Center (APDIC) in Tucson over a period of 3 years, from January 2017 to December 2019. RESULTS: We followed 1952 (44.4%) of the victims to resolution. We excluded 2253 callers with minimal effects of the sting and 193 victims with possible toxic effects who were lost to follow-up. The most common complaints among callers were pain at the sting site in 88.9% and local numbness in 62.2%. Detailed clinical information was obtained from 593 calls from a health care facility. Neuromotor signs consistent with C. sculpuratus envenomation included nystagmus in 163 (27.5%), hypersalivation in 91 (15.3%), and fasciculations in 88 (14.8%). Antivenom (Anascorp; Rare Disease Therapeutics, Inc., Franklin, Tenn) was administered to 145 patients. Most were children <5 years old (n = 76, or 54.4%); 27 (18.6%) were 5-9 years old and 42 (30.0%) were ≥10 years of age. About half, 79 of 145 (54.5%) victims who received antivenom, met the APDIC recommended use criteria. CONCLUSIONS: Patients treated with antivenom exhibited a rapid resolution of symptoms without immediate or delayed hypersensitivity reactions. We recommend broadened availability of antivenom at sites where it is most needed.

Honeybee Stings in the Era of Killer Bees: Anaphylaxis and Toxic Envenomation.

BACKGROUND: Twenty-six years after the arrival of "killer bees" in Arizona, the entire state with the exception of high elevations in the north is populated with this bee variety and 11 people have died at the scene of massive bee attacks. METHODS: Because of the aggressive behavior of these bees we studied bee stings reported to the Arizona Poison and Drug Information Center. The center received 399 calls regarding 312 victims of bee stings from January 2017 to June 2019. Calls originated from private residences and emergency centers. RESULTS: Stings occurred at victims' home residences in 272 (84.7%) of cases and 24 (7.5%) in public areas; 251 people suffered 1 sting; 42 individuals, 2-10 stings, 4 had 11-49 stings, and 13 individuals had >50 stings (so-called massive stinging). Three individuals were admitted to intensive care units (ICU) and one 35-year-old man died of anaphylaxis after 1 sting; moderate clinical effects occurred in 32 individuals including 6 admitted to the hospital but not in the intensive care unit. Anaphylaxis occurred in 30 (9.6%) of individuals, 16 receiving 1 sting. Toxic effects, tachycardia, elevated creatinine, or rhabdomyolysis occurred in 13 (4.2%) individuals. CONCLUSIONS: In the past, individuals stung more than 50 times were beekeepers working with European honeybees, whereas, in the current era, single as well as massive stings are the result of feral "killer bees." This change in epidemiology requires a new approach to sting victims: those with massive stinging should be evaluated and observed for anaphylaxis and serial laboratory values obtained for days to detect the toxic effects of envenomation.

Warnings for drug-drug interactions in consumer medication information provided by community pharmacies.

OBJECTIVES: In 2006, the U.S. Food and Drug Administration (FDA) issued a draft guidance for pharmacies to provide consumer medication information (CMI) to patients receiving prescription medications. The objective of this study was to evaluate CMI leaflets provided by community pharmacies for accuracy and completeness regarding drug-drug interactions (DDIs). METHODS: CMI leaflets were obtained for 3 commonly prescribed medications (azithromycin, ciprofloxacin, and simvastatin) from 14 community pharmacies that are part of 6 chain organizations that operate in southern Arizona. Three to 4 salient interacting medications for each leaflet medication were identified with the use of 2 well recognized drug compendia. The content of the DDI information in the leaflets was evaluated for completeness. The font size and reading level of each leaflet were assessed as well. RESULTS: The CMI provided by 14 pharmacies appeared to be produced by 2 information vendors, Wolters Kluwer and First Databank. This was evident based on the identical wording and attribution (e.g., copyright statements) on the leaflets. The CMI from First Databank mentioned 5 of the 11 previously identified interactions with the target medications, although 1 chain in this group chose not to print the DDI section at all and as a result scored 0. The CMI developed by Wolters Kluwer mentioned only 2 of the 11 identified DDIs. The average reading grade level for First Databank leaflets was 10.6 (SD 2.87), and the reading level for the CMI from Wolters Kluwer was 5.0 (SD 1.02). The font sizes varied from 8 to 12 points; FDA recommends that the information be printed in 12-point size or larger. CONCLUSION: Community pharmacies appear to be distributing CMI leaflets with limited warnings about serious and well known DDIs. The results of this study suggest that consumers are not being informed through the CMI about important known DDIs.

Prophylactic Antibiotics Are Not Needed Following Rattlesnake Bites.

BACKGROUND: Antibiotics are sometimes administered to victims of rattlesnake bites in the hope of preventing infections. Experts in the field recommend that prophylactic antibiotics not be used because secondary infections are rare. Current recommendations are based on a small number of studies conducted in the United States. We decided to reexamine the issue by taking advantage of a large database on snakebites in Arizona. This allowed us to determine how often prophylactic antibiotics were used and whether or not they were effective. METHODS: We obtained data from the Arizona Poison and Drug Information Center electronic medical record, Toxicall. Rattlesnake bites occurring over 18 years (1999-2016) were analyzed according to the descriptors: infection, pus, isolation of bacteria, and antibiotic use. RESULTS: There were 2748 evaluable patients identified as having rattlesnake bites. The mean number of bite victims was 153 per year. Most (72%) were male. Their ages ranged from 8 months to 91 years. Prophylactic antibiotics were administered to 120 of 2748 (4.4%) victims. There were 27 postbite infections (0.98%) but no deaths. Victims sometimes manipulated the wound sites. Microorganisms were isolated from only 9 patients. Only a Salmonella sp. was of certain reptilian origin; the others were likely of human origin. CONCLUSIONS: This large study supports recommendations that prophylactic antibiotics not be used following rattlesnake bites in the United States. The incidence of postbite infections was low, <1%. All but 1 of the bacteria isolated from the wounds were common inhabitants of human skin and not found in oral secretions of rattlesnakes.

Centruroides sculpturatus envenomation in three adult patients requiring treatment with antivenom.

CONTEXT: Envenomation by Centruroides sculpturatus can manifest with cranial nerve dysfunction and neuromuscular hyperactivity. While these symptoms are most commonly seen in young children, they may also be seen in adults. CASE DETAILS: Three cases of adult patients are presented with grades III & IV scorpion envenomation. They reported symptoms including disconjugate, roving eye movements, and motor involvement. Also reported were hyposmia, difficulty with fine motor movements, and dysgeusia. All were first treated with benzodiazepines with little to no effect. They then received a three vial antivenom bolus with resolution of severe symptoms within 30-60 min. DISCUSSION: Severe Centruroides envenomation can occur in adults as well as children. These three cases demonstrate the usefulness, safety, and effectiveness of antivenom therapy to quickly relieve symptoms in adult patients with grades III & IV envenomations.

Kissing Bug (Triatoma spp.) Intrusion into Homes: Troublesome Bites and Domiciliation.

Kissing bugs (Triatoma spp.) frequently enter homes and bite human and pet occupants. Bites may lead to severe allergic reactions and, in some cases, death. Kissing bugs are also vectors of Trypanosoma cruzi, the cause of Chagas disease. In general, modern houses in the United States are not conducive to domiciliation of kissing bugs (bugs living out their entire life within the home with the presence of eggs, nymphs, adults, and exuviae). Construction features such as concrete foundations, solid walls and ceilings, window screens, tight thresholds for doors and windows, and other measures impede bug entry into homes, and air conditioning reduces the need for open doors and windows. Where Chagas disease is endemic in Mexico and Central and South America, homes often have thatch roofs, adobe walls, and open doors and windows. We investigated numerous instances of kissing bug intrusions into homes in Southern Arizona, California, and Louisiana and documented the reactions to kissing bug bites. Our work confirms the importance of modern home construction in limiting kissing bug intrusions. Older homes, especially those lacking modern screening, caulking, and weather stripping to reduce air leakage, may be subject to kissing bug intrusions and domiciliation. We describe a community in Southern Arizona where domiciliation of homes by Triatoma recurva is common. We also provide recent data regarding kissing bug bites and allergic reactions to the bites.