166 Correspondence / American Journal of Emergency Medicine 36 (2018) 134–168

Table 3

Multivariable analysis of clinical outcomes of pulmonary tuberculosis patients associated with homelessness

So Yeon Kong, PhD, MPH Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Republic of Korea

26 June 2017

discontinuation of medication was 1.11 (0.42-2.94), for completion of therapy was 0.55 (0.21-1.38), and for mortality was 2.50 (0.92-6.79) in the non-homeless and the homeless (Table 3).

In this study, among the patients who visited the emergency depart- ment, the diagnostic rate of tuberculosis was 1.06% for homeless group, which was three times that of non-homeless, similar to the previous studies [7,8]. The self-discontinuation of medication rate was high in homeless than non-homeless group, and completion of therapy was low in homeless group. Mortality rate of homeless was more than twice as high as non-homeless, and it was still higher after adjusting for other risk factors such as sex, age, and underlying disease. These re- sults were similar with the previous studies [5,9,10]. Alcohol drinking and smoking rate for homeless were 45.7% and 54.3%, and those were higher than non-homeless group (19.0% and 25.6%). Alcohol intake over 40 g per day or alcohol addiction induce the risk of active tubercu- losis three times high. Also, alcohol affects the pharmacokinetics of tu- berculosis drugs, so it also affects treatment failure, relapse, and the development of resistant bacteria [11,12]. A large-scale study in India reported that the incidence of tuberculosis in smokers is higher than non-smokers, the mortality rate from tuberculosis is also higher, and the amount of smoking is proportional to the incidence of tuberculosis [13,14]. The proportion of patients visiting the emergency department through an ambulance was higher in the Homeless patients, which was similar in recent domestic study [7]. It is presumed that they usually visit the ER when after a long period of time had passed since the onset of the disease.

In our study, Homeless tuberculosis patients who visited emergency department of a public hospital had a higher rates of alcohol drinking, smoking, self-discontinuation of medication, mortality, and ICU admis- sion and lower rate of completion of therapy compared to the non- homeless tuberculosis patients. To prevent the spreading of tuberculo- sis into local community, it is necessary to introduce active medical treatment of the homeless patients, such as support to quit alcohol drinking and smoking and follow them up for a sufficient amount of time.

Acknowledgement

This work was supported by INHA University Hospital Research Grant.

Young Woong Hwang, MD

Department of Emergency Medicine, National Medical Center, 245 Euljiro,

jung-u, Seoul, Republic of Korea

Yu Jin Lee, MD, PhD

Department of Emergency Medicine, Inha University Hospital,

Republic of Korea Corresponding author at: Department of Emergency Medicine, Inha University Hospital, 27 Inhang-Ro, Jung-Gu, Incheon, Republic of Korea.

E-mail address: eyeblack99@gmail.com

http://dx.doi.org/10.1016/j.ajem.2017.07.049

References

1. WHO. Global TB Rep 2015:2015.
2. Welfare MoHa. Korea Centers for Disease Control and Prevention. Infectious Dis- eases Surveillance Yearbook, 2014; 2015.
3. Prevention KCfDCa. Annual Report on the Tuberculosis Cases Notified in Korea, 2015; 2016.
4. Dasisugi Homeless Health and Welfare Center. Report of Dasisugi Homeless Health and Welfare Center 2016; 2015.
5. Bamrah S, Yelk Woodruff RS, Powell K, Ghosh S, Kammerer JS, Haddad MB. Tubercu- losis among the homeless, United States, 1994-2010. Int J Tuberc Lung Dis 2013; 17(11) (1414-9).
6. Khan K, Rea E, McDermaid C, Stuart R, Chambers C, Wang J, et al. Active tuberculosis among homeless persons, Toronto, Ontario, Canada, 1998-2007. Emerg Infect Dis 2011;17(3):357-65.
7. Park KJ, Shin SD, Park CB, Hong KJ, Shin JH, Song KJ, et al. Comparison of clinical char- acteristics of pulmonary tuberculosis between general and homeless patients. J Ko- rean Soc Emerg Med 2012;23(6):847-52.
8. Kim HJ. Current status of tuberculosis in Korea. Korean J Med 2011;82(3):257-62.
9. Haddad MB, Wilson TW, Ijaz K, Marks SM, Moore M. Tuberculosis and homelessness in the United States, 1994-2003. JAMA 2005;293(22):2762-6.
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    and homelessness in Montreal: a retrospective cohort study. BMC Public Health 2011;11(1):833.

    Lonnroth K, Williams BG, Stadlin S, Jaramillo E, Dye C. Alcohol use as a risk factor for tuberculosis – a systematic review. BMC Public Health 2008;8(1):289.

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    ciation between alcohol use, Alcohol use disorders and tuberculosis (TB). A system- atic review. BMC Public Health 2009;9(1):450.

    Gajalakshmi V, Peto R, Kanaka TS, Jha P. Smoking and mortality from tuberculosis and other diseases in India: retrospective study of 43000 adult male deaths and 35000 controls. Lancet 2003;362(9383):507-15.

12. Kolappan C, Gopi PG. Tobacco smoking and pulmonary tuberculosis. Thorax 2002; 57(11):964-6.

    Clinical outcomes after Kratom exposures: A poison center case series

    

    Kratom (Mitragyna speciosa) is a tropical tree indigenous to South- east Asia, Philippines and New Guinea. It has been used to combat fa- tigue, in religious ceremonies and as an opium substitute for centuries [1]. Kratom use has increased recently; likely a combination of its un- scheduled status in the United States, availability from local stores or from the internet, and the current opioid use epidemic [2,3].

    Kratom has been used for self-treatment of Opioid withdrawal, chronic pain and recreationally [2,4,5]. It has stimulatory properties at low doses and opioid effects at higher doses because of the agonist ac- tivity of mitragynine and 7-hydroxymitragynine at the supraspinal mu and delta receptors [1,4,6].

    There is little data on the clinical toxicity of kratom. Kratom expo- sures presenting to the emergency department are likely to increase due to the nationwide opioid crisis. Therefore, the aim of this study is to summarize the clinical effects of kratom in a series of cases reported to our regional poison center.

    This was a retrospective cross-sectional study using electronic poi- son center data evaluating clinical outcomes from kratom exposure. This study was deemed exempt by our institutional review board.

    The electronic database Toxicall(TM) was searched from January 1, 2002 to November 30, 2016 using the key words: kratom and Mitragyna speciosa. Poison center charts were abstracted onto a data collection tool with no patient identifying information.

    Cases were reviewed by all authors and abstracted onto a spread- sheet. Inclusion criteria included all cases of kratom exposure referred

    Correspondence / American Journal of Emergency Medicine 36 (2018) 134–168 167

    Table 1

    Study demographics.

    Characteristics

    N= 12

    properties, kratom presumably could be used by athletes attempting to combat fatigue and pain.

    Our case series of kratom exposures is limited by no laboratory con-

    firmation of the presence of mitragynine. Kratom may not have been

    Age median (range) 25 (1 d-60 y)

    Male 8

    Female 4

    Reason for exposure

    Recreational 6

    Suicidal 1

    Therapeutic 3

    Withdrawal 1

    Unknown 1

    to a Healthcare facility. Cases were excluded if there were co-ingestants that could potentially confound assessment of signs or symptoms attrib- utable to kratom.

    The primary outcome was to summarize the clinical effects of kratom exposures. Specific variables included: vital signs, altered men- tal status, agitation, central nervous system depression, seizure, tremor, nausea, abdominal pain, and jaundice. Laboratory data, when available was recorded. Additional clinical data included therapies administered and hospital disposition.

    A total of fifteen cases reported from healthcare facilities were iden- tified during the study period. Three were excluded because the clinical effects were more consistent with the co-ingestants. Subject demo- graphics are shown in Table 1. The majority of exposures were coded as ingestion 10/12 (83%). The dose and frequency of use were largely unknown. Recreational use was the most common reason for exposures 5/12 (42%). Clinical effects are summarized in Table 2. There were no fa- talities or intensive care admissions.

    Median presenting vital signs included: heart rate of 102 bpm, blood pressure 151/89 mm Hg, respiratory rate 20 rpm, pulse oximetry of 99% and temperature 37 ?C. Electrocardiograms obtained on three patients had a median QRS of 114 ms and QTc of 476 ms, and no dysrhythmias were described. Table 3 summarizes selected cases.

    Benzodiazepines 4/12 (33%) were the most frequently used treat- ment. Admissions occurred in 6/12 (50%) of cases. Half were admitted

    used or other substances could have been ingested instead of or in com- bination with kratom. Much of our knowledge about kratom is from limited observations without confirmatory testing [1,4,6,7,9,14].

    The data are also limited by the retrospective nature of this

    study. Poison center data are generated passively through discus- sions with healthcare providers and poison center specialists that can result in incomplete documentation of important clinical information.

    This series illustrates kratom is being used for recreation, anal- gesia, treatment of opioid addiction and withdrawal prevention, performance enhancement and as a suicidal agent. There was a combination of opioid effects, seizures, tachycardia, and withdraw- al. Elevated bilirubin was seen after chronic use in one patient. None of the patients required intensive care when using kratom alone.

    Author declaration

    We wish to confirm that there are no known conflicts of interest as- sociated with this publication and there has been no significant financial support for this work that could have influenced its outcome.

    We confirm that the manuscript has been read and approved by all named authors and that there are no other persons who satisfied the criteria for authorship but are not listed. We further confirm that the order of authors listed in the manuscript has been approved by all of us.

    We confirm that we have given due consideration to the protection of intellectual property associated with this work and that there are no impediments to publication, including the timing of publication, with respect to intellectual property. In so doing we confirm that we have followed the regulations of our institutions concerning intellectual property.

    Table 3

    Clinical data for selected patients.

    to psychiatry. The mean length of stay for the cases with data, was 22 h. Seizures were more frequently reported in our cases than described

    Patient number

    Age Summary of clinical effects

    previously in the United States [7,8]. Likewise, neonatal opioid absti- nence syndrome was described beforehand only in Thailand. There, where the use of this native tree is more prevalent, researchers identi- fied 12 out of 52 cases experiencing kratom withdrawal. One was a two day old with increased tone and diaphoresis and was treated with supportive care [9].

    Intrahepatic cholestasis with markedly elevated bilirubin levels in association with kratom use has been previously reported [10-12]. Our patient had underlying nonalcoholic steatohepatitis and experienced nausea, abdominal pain and jaundice after daily use of kratom.

    Using kratom as a performance enhancing agent has already been acknowledged by the World Anti-Doping Agency and is on their moni- toring list [13]. Due to a combination of stimulatory and analgesic

    Table 2

    Summary of clinical effects.

    60 year o Therapeutic us of kratom for analgesia

    • Stopped prescribed lupus medications and started kratom, one teaspoon TID for one month
    • Discovered to have elevated transaminases and bilirubin
    • Gastroenterology service found no other etiologies
    • Treated with 21 h of n-acetylcysteine and transaminases improved

13. 1 day o Neonatal abstinence syndrome
    • Neonate born from a mother using kratom during pregnan- cy
    • Pt. subsequently developed diarrhea and tachypnea
    • Diagnosed neonatal Opioid abstinence syndrome by neona- tologist
    • Treated with a combination of benzodiazepines, morphine and intraVenous rehydration
    • Drug testing results of the mother and neonate are un- known
    • Treatment with morphine sulfate and benzodiazepines
14. 45 year o athletic performance enhancement

    Clinical effects			Intermittently ingested kratom for the past ten months In preparation for a cycling race, took extra kratom
    Altered mental status	4 (33%)		Had a Generalized seizure and developed mild rhabdomyol-
    Agitation	3 (25%)		ysis
    CNS depression	3 (25%)		Negative urine drug screen and no abnormalities of electro-
    Seizure	3 (25%)		lytes
    Tachycardia	5 (42%)		Head CT with nasal bone fracture and soft tissue hematoma

    168 Correspondence / American Journal of Emergency Medicine 36 (2018) 134–168

    Kirk L. Cumpston, DO* Brandon K. Wills, DO

    Division of Clinical Toxicology, Department of Emergency Medicine, VCU

    Medical Center, Richmond, VA, United States Virginia Poison Center, Richmond, VA, United States Department of Emergency Medicine, VCU Medical Center, Richmond, VA,

    United States

    *Corresponding author at: VCU Health System, Virginia Poison Center,

    United States.

    E-mail address: kirk.cumpston@vcuhealth.org (Cumpston, K.L.).

    Michael Carter, MD

    Department of Emergency Medicine, VCU Medical Center, Richmond, VA,

    United States

    5 June 2017

    http://dx.doi.org/10.1016/j.ajem.2017.07.045

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15. Warner ML, Kaufman NC, Grundmann O. The pharmacology and toxicology of kratom: from traditional herb to drug of abuse. Int J Leg Med 2016;130:127-38.
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22. Pantano F, Tittarelli R, Mannocchi G, Zaami S, Ricci S, Giorgetti R, et al. Hepatotoxicity induced by “the 3Ks”: kava, kratom and khat. Int J Mol Sci 2016;17:580.
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    report. Hepatology 2015;61:1086-7.

    Kapp FG, Maurer HH, Auwarter V, Winkelmann M, Hermanns-Clausen M. Intrahepatic cholestasis following abuse of powdered kratom (Mitragyna speciosa). J Med Toxicol 2011;7:227-31.

24. Guddat S, Gorgens C, Steinhart V, Schanzer W, Thevis M. Mitragynine (kratom) —

    monitoring in sports drug testing. Drug Test Anal 2016.

    Singh D, Muller CP, Vicknasingam BK, Mansor SM. Social functioning of kratom (Mitragyna speciosa) users in Malaysia. J Psychoactive Drugs 2015;47:125-31.