Journal of Medical Toxicology https://doi.org/10.1007/s13181-020-00759-7 ANNUAL MEETING ABSTRACTS ACMT 2020 Annual Scientific Meeting Abstracts – New York, NY Abstract: These are the abstracts of the 2020 American College of Background: Oral cyanide is a potentially deadly poison and has the Medical Toxicology (ACMT) Annual Scientific Meeting. Included here potential for use by terrorists. There is potential for a mass casualty ex- are 174 abstracts that will be presented in March 2020, including research posure scenario, and currently, there are no FDA-approved antidotes spe- studies from around the globe and the ToxIC collaboration, clinically cifically for oral cyanide poisoning. significant case reports describing new toxicologic phenomena, and en- Hypothesis: We hypothesize that animals treated with oral sodium thio- core research presentations from other scientific meetings. sulfate will have a higher rate of survival vs. control in a large animal model of acute, severe, oral cyanide toxicity. Keywords Abstracts, Annual Scientific Meeting, Toxicology Methods: This is a prospective study that took place at the University of Investigators Consortium, Medical Toxicology Foundation Colorado Anschutz Medical Campus. Nine swine (45–55 kg) were in- strumented, sedated, and stabilized. Potassium cyanide (8 mg/kg KCN) in Correspondence: American College of Medical Toxicology (ACMT), saline was delivered as a one-time bolus via an orogastric tube. Three 10645 N. Tatum Blvd, Phoenix, AZ, USA; [email protected] minutes after cyanide, animals who were randomized to the treatment group received sodium thiosulfate (508.2 mg/kg, 3.25 M solution) via Introduction: The American College of Medical Toxicology (ACMT) re- orogastric tube. Survival at 60 minutes after exposure was the primary ceived 223 eligible research abstracts for consideration for presentation at the outcome. We compared survival between treatment and control groups by 2020 Annual Scientific Meeting (ASM), including 107 research studies and log-rank, Mantel–Cox analysis, and trended labs and vital signs. 116 case reports. Each abstract was reviewed in a blinded fashion by at least Results: At baseline and time of treatment, all animals were similar. four research committee members. Each abstract was independently scored Survival at 60 minutes was 100% in treated animals compared to 0% in based on the clinical question, data source, analytic method, results/conclu- the control group (p = 0.0027). Animals in the control group became sion, and clarity of presentation. A total of 177 abstracts were accepted. This apneic and subsequently died by 34.6 ± 15 minutes after cyanide expo- work would not be possible without the hard work and diligence of our sure. Mean arterial pressure was significantly improved between the treat- abstract reviewers: Justin Arnold, Katie Boyle, Jeffrey Brent, Keith ment and control group at study end (p < 0.0001). Blood lactate and Burkhart, Diane Calello, Stephanie Carreiro, James Chenoweth, Neeraj oxygen saturation were also significantly improved between treatment Chhabra, Nick Connors, Kirk Cumpston, Rob Hendrickson, Michelle and control at study end (p =0.0244andp = 0.0281, respectively). Hieger, David Jang, David Juurlink, Louise Kao, Kenneth Katz, Kate Conclusion: Oral administration of sodium thiosulfate improved survival Katzung, Russ Kerns, Andrew King, Kathy Kopec, JoAn Laes, Eric and physiological parameters in a large animal model of oral cyanide Lavonas, Michael Levine, David Liss, Gerald Maloney, Kevin Maskell, toxicity. William Meggs, Andrew Monte, Elissa Moore, Mark Mycyk, Travis Olives, Patricia Rosen, Evan Schwarz, Daniel Sessions, Samuel Stellpflug, 002. Outbreak of Hypoglycemia from Counterfeit “V8” Male Sexual Mark Su, Manoj Tyagi, Shawn Varne, Steven Walsh, Richard Wang, Sage Enhancement Supplements Wiener, Brandon Wills, and Luke Yip. Equally significant is the contribution of the ACMT staff (Adrienne Dunavin, Dana Karshenas, and Lizzy Nguyen) John W Downs1, Landon R Mueller1,OkeyFUtah2, Brandon K Wills1, who led the process. Congratulations to all the contributors whose work will Kirk L Cumpston1, S. Rutherfoord Rose1 be presented in New York. 1Virginia Commonwealth University Health System, Richmond, VA, USA. 2Richmond City Health District, Richmond, VA, USA We look forward to seeing you there. Background: Over-the-counter male sexual enhancement supplements may Jon B. Cole, MD, FACMT, Abstract Review Chair; Christine Murphy, contain undisclosed prescription pharmaceuticals such as phosphodiesterase- MD, FACMT, Abstract Review Co-Chair; Maryann Amirshahi, PharmD, 5 inhibitors. For unclear reasons, other pharmaceutical contaminants may be MD, MPH, PhD, FACMT, Chair, ACMT Research Committee present. This report describes an investigation of an outbreak of unexplained hypoglycemia associated with the use of an adulterated, counterfeit male ACMT 2020 Annual Scientific Meeting Abstracts – New York, NY sexual enhancement supplement called “V8.” Hypothesis: “V8” male sexual enhancement supplement contains a sul- Day 1: Platforms, Abstracts 001–004 fonylurea contaminant resulting in symptomatic hypoglycemia. Methods: This was an urgent prospective cohort study conducted as an 001. Efficacy of Oral Sodium Thiosulfate for Acute, Severe Oral outbreak investigation in conjunction with local and state public health Cyanide Toxicity in Swine authorities. Cases were defined as persons with unexplained hypoglyce- mia who reported use of “V8” male enhancement supplement. Cases Patrick C Ng1, Tara B Hendry-Hofer2, Joseph K Maddry3, Vikhyat S were obtained through calls to the Virginia Poison Center. Case discovery Bebarta2 and dissemination of information included health care facility notifica- 1Brooke Army Medical Center, Fort Sam Houston, TX, USA. 2University tion, press release, and social media posts. Biologic samples and product of Colorado Anschutz Medical Campus, Aurora, CO, USA. 3En Route samples were submitted to the Virginia Department of Health Laboratory Care and Research Center, Fort Sam Houston, TX, USA for analysis for culprit contaminants. J. Med. Toxicol. Results: Seven cases of unexplained symptomatic hypoglycemia associ- 1Department of Medicine, University of Maryland Medical School, ated with V8 male enhancement supplement use were reported to the Baltimore, MD, USA. 2University of Maryland A. James Clark School Virginia Poison Center over a 4-week period. All cases were treated with of Engineering, College Park, MD, USA. 3Department of Surgery, supplemental dextrose and octreotide. All were admitted for a minimum University of Maryland Medical School, Baltimore, MD, USA. of 24 hours of observation. Lowest recorded blood glucose concentra- 4Maryland Poison Center, Baltimore, MD, USA tions ranged from 26 to 48 mg/dL (median 32 mg/dL). Median hospital length of stay was 2 days. Product samples were obtained from retail Background: Extracorporeal removal of toxins is limited by the amount locations as well as from cases. Product testing at the state public health of blood which can be processed over a given time period. Extracorporeal laboratory confirmed glyburide estimated at 90–100 mg per tablet, as well membrane oxygenation (ECMO) processes blood roughly ten times faster as sildenafil ranging 55–156 mg per tablet. Three cases had serum sulfo- than conventional hemodialysis. We recently demonstrated that high- nylurea screens performed and all three were positive for glyburide. No volume hemofiltration in a patient undergoing ECMO is achievable, of- adverse effects of sildenafil were reported. fering the possibility of markedly increased extracorporeal toxin Conclusion: Counterfeit male sexual enhancement supplements contained elimination. prescription sildenafil and glyburide, which produced life-threatening hypo- Hypothesis: A high-volume hemofiltration system within an ECMO cir- glycemia. These patients required admission and treatment of prolonged, cuit allows for superior extracorporeal toxin removal compared to con- refractory hypoglycemia with dextrose and supplemental octreotide. ventional hemodialysis. Methods: This is an in vitro single-compartment model of an ECMO 003. Assessment of the Overdosage Section of Labeling for Drugs circuit with an in-line high-volume hemofiltration system. A primary Highly Associated with Drug Poison Fatalities closed circuit with 5 L of 0.9% saline and 6.8 mg/L flecainide acetate (approximating a 5000-mg ingestion in an 80-kg person) was connected Keith K Burkhart, Eric Brodsky to Revaclear© hemodialysis filters attached in parallel. A centrifugal Food and Drug Administration, Silver Spring, MD, USA blood pump (CentriMag©) drove the primary circuit at a flow rate of 4 L/minute, while two separate pumps were used to remove effluent Background: FDA regulations require the overdosage section of labeling and infuse replacement fluid (saline). A trial with two hemodialysis filters for human prescription drugs be updated when new information becomes was performed, followed by a second trial with eight filters. Flecainide available that causes the labeling to become inaccurate, false, or mislead- concentration of samples drawn periodically was determined with ing [21 CFR 201.57(c)(11) and 21 CFR 201.56(a)(2)]. ultraviolet–visible spectroscopy, and removal rates were calculated. Methods: We compared the overdosage management recommendations Results: In the two-filter circuit, effluent flow rate of 0.4 L/minute was in the overdosage section of 29 selected labeling to overdosage manage-