Correspondence / American Journal of Emergency Medicine 37 (2019) 1784-1805 1803

review data for Montgomery County shows increasing methamphet- amine associated overdose deaths, nearly doubling between 2016 and 2017 [1].

We hypothesized that the increase in the diagnosis and prescrip- tions for Attention Deficit Hyperactivity Disorder (ADHD) over the past several years may be contributing to the observed increasing rates of methamphetamine psychosis in our area [5]. This study was un- dertaken to identify any association of methamphetamine psychosis and prior prescriptions for stimulant ADHD medications.

In this retrospective study, eligible participants included patients with a diagnosis of methamphetamine overdose or psychosis between 10/ 2016 to 12/2017. This study was reviewed and approved as exempt re- search by the Wright State University Institutional Review Board. Meth- amphetamine toxicity or psychosis was confirmed. The prescription history of these patients was accessed using the prescription drug moni- toring program (PDMP). The system extracts prescription data for the past2 years from the date in which the chart was accessed. The amount and the date of the prescription for any stimulant ADHD medication was recorded. Following extraction of this data, patient records were deidentified and the results tabulated as described below.

Participants included 48 subjects with methamphetamine psychosis or overdose. Participants were 68% male, 92% Caucasian and ranging in age from 18 to 65 year (median 30). None of these cases had an identified prescription for stimulant medication within the most recent 2 years. Therefore, there was no association between patients presenting to the ED with signs and symptoms of Methamphetamine intoxication and hav- ing received a recent prescription for any ADHD stimulant medication prior to their presentation.

Over the past decade prescriptions for ADHD medications have doubled [6]. In light of this increase, we attempted to determine whether there was an association between methamphetamine over- dose and a recent prescription for an amphetamine based ADHD medication. We were concerned that, not unlike what was noted re- garding the opiate epidemic, recent increases in the frequency of pa- tients presenting to the emergency department may have been associated with amphetamine-based ADHD medication prescribing. However, this study did not identify any associated amphetamine prescription among ED patients with methamphetamine psychosis or overdose.

Due the limitations of the prescription drug monitoring pro- gram (PDMP) in use, remote prescriptions may not have been iden- tified. Our study was also limited in the fact that the PDMP does not identify non-prescribed stimulant use, unauthorized use of pre- scription medication from another patient, or a more remote pre- scription history. Non-prescribed stimulant use is common among middle, high school, college, and medical students, both recreationally and as an aid in studying [7,8,9]. It is possible that recreational use of stimulants could lead to drug abuse later in life. Further directions will focus on the role of ADHD medication prescribing in childhood and early adolescence in the subsequent development of methamphetamine addiction.

Dennis M. Mann? Catherine A. Marco John P. Detherage III Peter J. Greene Daniel E. Ross

Wright State University Boonshoft School of Medicine, Department of Emergency Medicine, 3585 Southern Blvd, Kettering, OH, 45429, United

States of America

?Corresponding author.

E-mail address: [email protected].

https://doi.org/10.1016/j.ajem.2019.03.018

References

1. Richards JR, Hamidi S, Grant CD, Wang CG, Tabish N, Turnipseed SD, Derlet RW. Meth- amphetamine use and emergency department utilization: 20 years later. J Addict 2017; 2017: 4050932.
2. Poisoning Death Review Report Montgomery County, 2017. Public Health-Dayton & Montgomery County Prepared by Epidemiology Department Published July 2, 2018.
3. Glasner-Edwards S, Mooney LJ. Methamphetamine psychosis: epidemiology and management. CNS Drugs 2014; 28 (12): 1115-26.
4. McKetin R, Lubman DI, Baker AL, Dawe S, Ali RL Dose-related Psychotic symptoms in chronic methamphetamine users: evidence from a prospective longitudinal study. JAMA Psychiat 2013 Mar; 70(3): 319-24.
5. McKetin R1, Lubman DI, Baker AL, Dawe S, Ali RL. American Psychiatric Association: Diagnostic and statistical manual of Mental disorders, 5th edition. Arlington, VA., American Psychiatric Association, 2013.
6. Piper BJ, Ogden CL, Simoyan OM, Chung DY, Caggiano JF, Nichols SD, et al. (2018) Trends in use of prescription stimulants in the United States and Territories, 2006 to 2016. PLoS ONE 13 (11): e0206100. Available at: https://journals.plos.org/ plosone/article?id=10.1371/journal.pone.0206100, Accessed 2/6/2019.
7. Leon KS, Martinez DE. To study, to party, or both? Assessing risk factors for non- prescribed stimulant use among middle and high school students. J Psychoactive Drugs 2016; 49(1): 22-30.
8. Burgard DA, Fuller R, Becker B, Ferrell R, Dinglasan-Panlilio M. Potential trends in atten- tion deficit hyperactivity disorder (ADHD) drug use on a college campus: wastewater analysis of amphetamine and ritalinic acid. Sci Total Environ 2013; 450-451: 242-249.
9. Fond G, Gavaret M, Llorca P, Boyer L, Micoulaud-Franchi J, Domenech P. (Mis)use of prescribed stimulants in the medical student community: motives and behaviors. A population-based cross-sectional study. Eur Neuropsychopharmacol 2016; 26.

   Comments on GEDI vs. CVP goal-directed fluid resuscitation for chronic obstructive pulmonary disease patients with septic shock: A randomized controlled trial

   To the Editor,

   We have greatly enjoyed reading the article by Yu et al. [1],which was a single-center, prospective, randomized, controlled trial (RCT) compared the effects of global end-diastolic volume index vs. central venous pressure goal-directed fluid resuscitation for chronic obstructive pulmonary disease (COPD) patients with septic shock. The authors con- clude that GEDI goal-directed fluid resuscitation shows better clinical ef- fects compared to CVP for COPD patients with septic shock.

   We would like to add several appreciations. First, the author defined a targeted endpoint CVP of 12 mmHg based on the 2008 SSC guidelines. [2] However, the 2008 SSC guidelines recommended a targeted endpoint CVP of 15 mmHg in patients with mechanical ventilation, not 12 mmHg for mechanical ventilation decreasing venous return. The normal range of GEDI is 680-800 ml/m² [3]. The low targeted endpoint CVP of 12 mmHg could result in lower fluid volume and higher norepinephrine dosage. Second, the main endpoints were fluid volume, NE dosage, ICU mortality rate, blood Lactate clearance rate and ICU length of stay. Never- theless, it is common for sample size to be based on the primary outcomes alone. The author did not explain the calculation of sample size (71 pa- tients). blood lactate clearance rate could assess the mortality rate of pa- tients with sepsis shock during hospitalization with high specificity and sensitivity [4]. Thus, I suggest that the author could define blood lactate clearance rate as the only primary outcome and calculate the sample size based on it. Fourth, the lack of blinding could lead to observer bias in length of ICU stay and duration of mechanical ventilation. At last, ac- cording to 2008 SSC guidelines, [1] norepinephrine and dopamine were recommend as the first vasopressors agent, epinephrine should be the first alternative agent when septic shock is poorly responsive to them and dobutamine was recommend in patients with myocardial dysfunc- tion. Hence, the types and doses of total vasopressors administration not just norepinephrine should be provided.

   Abbreviations: GEDI, Global end-diastolic volume index; CVP, central venous pressure; COPD, chronic obstructive pulmonary disease; RCTs, random, controlled trails.

   1804 Correspondence / American Journal of Emergency Medicine 37 (2019) 1784-1805

   Funding

   None.

   Commentary on prophylactic systemic antibiotics for anterior epistaxis treated with nasal packing in the emergency department

   Ethical approval and consent to participate

   Not applicable.

   Consent for publication

   Not applicable.

   Availability of supporting data

   Not applicable.

   Conflicts of interest

   All authors report no conflicts of interest.

   Acknowledgements

   None.

   Bojun Chen? Hairong Cai Shuai Zhao Zhishang Li

   Dear Editor,

   We read with great interest the paper entitled “Prophylactic sys- temic antibiotics for anterior epistaxis treated with nasal packing in the emergency department” by Murano et al. [1]. The authors compared the infection rate between patients who were and were not prescribed prophylactic systemic antibiotics for anterior nasal packing in spontane- ous epistaxis. They found that Prophylactic antibiotic use for nasal pack- ing in spontaneous epistaxis patients is unnecessary. This is an excellent study, and may help to avoid the abuse of antibiotics. However, there are areas that require further clarification.

   The infection rate is related to the nasal packing material. Iodo-

   form (or petrolatum) gauze increased the injury to the nasal mucosa and, thereby, induced infection of the nasal cavity. On the contrary, some biological materials including Merocel, absorbable styptic gauze, etc. do not increase the nasal mucosal injury [2,3]. The authors found that the most common method of anterior packing was the use of intranasal balloon devices (74/106, 69.8%), followed by foam poly- mer nasal tampon use (29/106, 27.3%) [1]. However, the type of packing material used in the remaining three cases was not discussed. The authors should, therefore, compare the infection rate between different packing materials in a future study. In addi- tion, the duration of pack use can affect the infection of the nasal cav- ity. In this study, the pack was usually removed within 48-72 h after admission. However, the duration of pack use was increased because of the recurrence of epistaxis. The prolonged duration of pack use

   The Second Clinical Medical College of Guangzhou University of Chinese Medicine, Guangzhou 510405, Guangdong Province, China Department of Emergency, the Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510120, Guangdong Province,

   China.

   Corresponding author: *

   E-mail address: [email protected].

   Shuling Liu Weizhang Zhang Lieyuan Zhang

   Jing Zeng Xingui Cai Yongning Guo

   Department of Emergency, the Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510120, Guangdong Province,

   China.

   3 March 2019

   would cause obstruction of the ostiomeatal complex and affect drainage of the nasal sinus, thereby increasing the chance of infec- tion of the nasal sinus [4]. Thus, we believe that prophylactic antibi- otic use should be considered in this case.

   Funding source

   No.

   Conflict of interest

   No.

   Zhengcai Lou, MD Department of Otorhinolaryngology, The Affiliated Yiwu Central Hospital, 699 Jiangdong Road, Yiwu City 322000, Zhejiang Province, China

   E-mail address: [email protected].

   https://doi.org/10.1016/j.ajem.2019.03.019

   References

   https://doi.org/10.1016/j.ajem.2019.03.020

   16 February 2019

   Yu J, Zheng R, Lin H, et al. Global end-diastolic volume index vs central venous pres- sure goal-directed fluid resuscitation for chronic obstructive pulmonary disease pa- tients with septic shock: a randomized controlled trial [J]. Am J Emerg Med 2016;35

   (1):1-24. https://doi.org/10.1016/j.ajem.2016.10.015.

   Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2008[J]. Intensive Care Med 2008;34:17-60. https://doi.org/10.1007/s00134-007-0934-2.

10. Huber W, Umgelter A, Reindl W, et al. Volume assessment in patients with necrotiz- ing pancreatitis: a comparison of intrathoracic Blood volume index, central venous pressure, and hematocrit, and their correlation to cardiac index and extravascular lung water index [J]. Crit Care Med 2008;36(8):2348. https://doi.org/10.1097/CCM. 0b013e3181809928.
11. H Bryant N, Rivers EP, Knoblich BP, et al. Early lactate clearance is associated with im- proved outcome in severe sepsis and septic shock.[J]. Crit Care Med, 2004, 32(8): 1637. doi:https://doi.org/10.1097/01.CCM.0000132904.35713.A7.

    References

    Murano T, Brucato-Duncan D, Ramdin C, Keller S. Prophylactic systemic antibiotics for anterior epistaxis treated with nasal packing in the emergency department. Am J Emerg Med 2019;37(4):726-9.

12. Iqbal IZ, Jones GH, Dawe N, Mamais C, Smith ME, Williams RJ, et al. Intranasal packs and haemostatic agents for the management of adult epistaxis: systematic review. J Laryngol Otol 2017;131:1065-92.
13. Perez F, Rada G. Is antibiotic prophylaxis in nasal packing for anterior epistaxis needed? Medwave Jan 7 2016;16(Suppl. 1):e6357.
14. Viducich RA, Blanda MP, Gerson LW. Posterior epistaxis: clinical features and acute complications. Ann Emerg Med 1995;25:592-6.