Welcome to the 2024 ACMT Annual Scientific Meeting.

Two hundred sixteen abstracts were selected for presentation at the 2024 American College of Medical Toxicology (ACMT) Annual Scientific Meeting on April 12-14, 2024, in Washington, DC. The quality and breadth of toxicology scholarship continues to grow as our field expands. The complete 2024 ASM abstract book in the April issue of JMT includes original research studies from around the world and the ToxIC Investigators Consortium, clinically significant case reports describing toxicologic phenomena, and selected encore research presentations from other scientific meetings.

Contactless Monitoring System Versus Gold Standard for Respiratory Rate Monitoring in Emergency Department Patients: Pilot Comparison Study.

BACKGROUND: Respiratory rate is a crucial indicator of disease severity yet is the most neglected vital sign. Subtle changes in respiratory rate may be the first sign of clinical deterioration in a variety of disease states. Current methods of respiratory rate monitoring are labor-intensive and sensitive to motion artifacts, which often leads to inaccurate readings or underreporting; therefore, new methods of respiratory monitoring are needed. The PulsON 440 (P440; TSDR Ultra Wideband Radios and Radars) radar module is a contactless sensor that uses an ultrawideband impulse radar to detect respiratory rate. It has previously demonstrated accuracy in a laboratory setting and may be a useful alternative for contactless respiratory monitoring in clinical settings; however, it has not yet been validated in a clinical setting. OBJECTIVE: The goal of this study was to (1) compare the P440 radar module to gold standard manual respiratory rate monitoring and standard of care telemetry respiratory monitoring through transthoracic impedance plethysmography and (2) compare the P440 radar to gold standard measurements of respiratory rate in subgroups based on sex and disease state. METHODS: This was a pilot study of adults aged 18 years or older being monitored in the emergency department. Participants were monitored with the P440 radar module for 2 hours and had gold standard (manual respiratory counting) and standard of care (telemetry) respiratory rates recorded at 15-minute intervals during that time. Respiratory rates between the P440, gold standard, and standard telemetry were compared using Bland-Altman plots and intraclass correlation coefficients. RESULTS: A total of 14 participants were enrolled in the study. The P440 and gold standard Bland-Altman analysis showed a bias of -0.76 (-11.16 to 9.65) and an intraclass correlation coefficient of 0.38 (95% CI 0.06-0.60). The P440 and gold standard had the best agreement at normal physiologic respiratory rates. There was no change in agreement between the P440 and the gold standard when grouped by admitting diagnosis or sex. CONCLUSIONS: Although the P440 did not have statistically significant agreement with gold standard respiratory rate monitoring, it did show a trend of increased agreement in the normal physiologic range, overestimating at low respiratory rates, and underestimating at high respiratory rates. This trend is important for adjusting future models to be able to accurately detect respiratory rates. Once validated, the contactless respiratory monitor provides a unique solution for monitoring patients in a variety of settings.

Informing Acceptability and Feasibility of Digital Phenotyping for Personalized HIV Prevention among Marginalized Populations Presenting to the Emergency Department.

For marginalized populations with ongoing HIV epidemics, alternative methods are needed for understanding the complexities of HIV risk and delivering prevention interventions. Due to lack of engagement in ambulatory care, such groups have high utilization of drop-in care. Therefore, emergency departments represent a location with those at highest risk for HIV and in highest need of novel prevention methods. Digital phenotyping via data collected from smartphones and other wearable sensors could provide the innovative vehicle for examining complex HIV risk and assist in delivering personalized prevention interventions. However, there is paucity in exploring if such methods are an option. This study aimed to fill this gap via a cross-sectional psychosocial assessment with a sample of N=85 emergency department patients with HIV risk. Findings demonstrate that although potentially feasible, acceptability of digital phenotyping is questionable. Technology-assisted HIV prevention needs to be designed with the target community and address key ethical considerations.

Beta-blocker and calcium-channel blocker toxicity: current evidence on evaluation and management.

Beta-blocker and calcium-channel blocker overdoses are associated with severe morbidity and mortality; therefore, it is important to recognize and appropriately treat individuals with toxicity. The most common clinical findings in toxicity are bradycardia and hypotension. In addition to supportive care and cardiac monitoring, specific treatment includes administration of calcium salts, vasopressors, and high-dose insulin euglycaemia treatment. Other advanced treatments (e.g. ECMO) may be indicated depending on the severity of toxicity and specific agents involved.

Preliminary feasibility of a wrist-worn receiver to measure medication adherence via an ingestible radiofrequency sensor.

Adherence to medications is a complex task that requires complex biobehavioral support. To better provide tools to assist with medication adherence, digital pills provide an option to directly measure medication taking behaviors. These systems comprise a gelatin capsule with radiofrequency emitter, a wearable Reader that collects the radio signal and a smartphone app that collects ingestion data displays it for patients and clinicians. These systems are feasible in measuring adherence in the real-world, even in stigmatized diseases like HIV treatment adherence. While the current iteration of the digital pill system utilizes a wearable Reader worn like a necklace, preliminary feedback demonstrated that a miniaturized system that was worn on the wrist could be more functional in the real-world. This paper therefore describes the development and preliminary field testing of a wrist-borne wearable Reader to facilitate acquisition of oral HIV pre-exposure prophylaxis (PrEP) adherence data among individual prescribed PrEP.

The therapeutic use and efficacy of ketamine in alcohol use disorder and alcohol withdrawal syndrome: a scoping review.

Introduction: Alcohol use disorder (AUD) is the most prevalent substance use disorder (SUD) globally. In 2019, AUD affected 14.5 million Americans and contributed to 95,000 deaths, with an annual cost exceeding 250 billion dollars. Current treatment options for AUD have moderate therapeutic effects and high relapse rates. Recent investigations have demonstrated the potential efficacy of intravenous ketamine infusions to increase alcohol abstinence and may be a safe adjunct to the existing alcohol withdrawal syndrome (AWS) management strategies. Methods: We followed Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines to conduct a scoping review of two databases (PubMed and Google Scholar) for peer-reviewed manuscripts describing the use of ketamine in AUD and AWS. Studies that evaluated the use of ketamine in AUD and AWS in humans were included. We excluded studies that examined laboratory animals, described alternative uses of ketamine, or discussed other treatments of AUD and AWS. Results: We identified 204 research studies in our database search. Of these, 10 articles demonstrated the use of ketamine in AUD or AWS in humans. Seven studies investigated the use of ketamine in AUD and three studies described its use in AWS. Ketamine used in AUD was beneficial in reducing cravings, alcohol consumption and longer abstinence rates when compared to treatment as usual. In AWS, ketamine was used as an adjunct to standard benzodiazepine therapy during severe refractory AWS and at signs of delirium tremens. Adjunctive use of ketamine demonstrated earlier resolution of delirium tremens and AWS, reduced ICU stay, and lowered likelihood of intubation. Oversedation, headache, hypertension, and euphoria were the documented adverse effects after ketamine administration for AUD and AWS. Conclusion: The use of sub-dissociative doses of ketamine for the treatment of AUD and AWS is promising but more definitive evidence of its efficacy and safety is required before recommending it for broader clinical use.

Experiences with Medications for Addiction Treatment Among Emergency Department Patients with Opioid Use Disorder.

INTRODUCTION: Medications for addiction treatment (MAT) are the evidence-based standard of care for treatment of opioid use disorder (OUD), but stigma continues to surround their use. We conducted an exploratory study to characterize perceptions of different types of MAT among people who use drugs. METHODS: We conducted this qualitative study in adults with a history of non-medical opioid use who presented to an emergency department for complications of OUD. A semi-structured interview that explored knowledge, perceptions, and attitudes toward MAT was administered, and applied thematic analysis conducted. RESULTS: We enrolled 20 adults. All participants had prior experience with MAT. Among participants indicating a preferred treatment modality, buprenorphine was the commonly favored agent. Previous experience with prolonged withdrawal symptoms upon MAT discontinuation and the perception of "trading one drug for another" were common reasons for reluctance to engage in agonist or partial-agonist therapy. While some participants preferred treatment with naltrexone, others were unwilling to initiate antagonist therapy due to fear of precipitated withdrawal. Most participants strongly considered the aversive nature of MAT discontinuation as a barrier to initiating treatment. Participants overall viewed MAT positively, but many had strong preferences for a particular agent. CONCLUSION: The anticipation of withdrawal symptoms during initiation and cessation of treatment affected willingness to engage in a specific therapy. Future educational materials for people who use drugs may focus on comparisons of respective benefits and drawbacks of agonists, partial agonists, and antagonists. Emergency clinicians must be prepared to answer questions about MAT discontinuation to effectively engage patients with OUD.

Emergency Medicine Provider Impressions of Novel SMS-Based Toxicology Module.

The diagnosis and treatment of common toxicologic disorders is an area of core content that emergency medicine (EM) resident physicians and physician assistants (PA) are required to demonstrate competence in order to become proficient practicing clinicians. Even when EM programs have a required toxicology elective, learners do not encounter all core toxicologic presentations. To supplement these knowledge gaps, many toxicology curriculums rely on internet learning modules which have variable uptake in practice. With remote learning and education becoming more common, we aim to perform a need-based assessment of EM resident and PA toxicology education and use the results to develop and deploy a text message-based, interactive toxicology supplemental program for EM residents and PAs and measure its acceptability and preliminary effectiveness to teach core toxicology principles.

Nobody Wants to Be Narcan'd: A Pilot Qualitative Analysis of Drug Users' Perspectives on Naloxone.

INTRODUCTION: Bystander naloxone distribution is an important component of public health initiatives to decrease opioid-related deaths. While there is evidence supporting naloxone distribution programs, the effects of increasing naloxone availability on the behavior of people who use drugs have not been adequately delineated. In this study we sought to 1) evaluate whether individuals' drug use patterns have changed due to naloxone availability; and 2) explore individuals' knowledge of, access to, experiences with, and perceptions of naloxone. METHODS: We conducted a pilot study of adults presenting to the emergency department whose medical history included non-medical opioid use. Semi-structured interviews were conducted with participants and thematic analysis was used to code and analyze interview transcripts. RESULTS: Ten participants completed the study. All were aware of naloxone by brand name (Narcan) and had been trained in its use, and all but one had either currently or previously possessed a kit. Barriers to naloxone administration included fear of legal repercussions, not having it available, and a desire to avoid interrupting another user's "high." Of the eight participants who reported being revived with naloxone at least once during their lifetime, all described experiencing a noxious physical response and expressed a desire to avoid receiving it again. Furthermore, participants did not report increasing their use of opioids when naloxone was available. CONCLUSIONS: Participants were accepting of and knowledgeable about naloxone, and were willing to administer naloxone to save a life. Participants tended to use opioids more cautiously when naloxone was present due to fears of experiencing precipitated withdrawal. This study provides preliminary evidence countering the unsubstantiated narrative that increased naloxone availability begets more high-risk opioid use and further supports increasing naloxone access.

Respiratory Rate Monitoring in Clinical Environments with a Contactless Ultra-Wideband Impulse Radar-based Sensor System.

Respiratory rate is an extremely important but poorly monitored vital sign for medical conditions. Current modalities for respiratory monitoring are suboptimal. This paper presents a proof of concept of a new algorithm using a contactless ultra-wideband (UWB) impulse radar-based sensor to detect respiratory rate in both a laboratory setting and in a two-subject case study in the Emergency Department. This novel approach has shown correlation with manual respiratory rate in the laboratory setting and shows promise in Emergency Department subjects. In order to improve respiratory rate monitoring, the UWB technology is also able to localize subject movement throughout the room. This technology has potential for utilization both in and out of the hospital environments to improve monitoring and to prevent morbidity and mortality from a variety of medical conditions associated with changes in respiratory rate.