Notes from the Field: Severe Illness Associated with Synthetic Cannabinoid Use — Brunswick, Georgia, 2013
November 22, 2013 / 62(46);939-939
On August 23, 2013, the Georgia Poison Center was notified of eight persons examined in an emergency department in Brunswick, Georgia, after smoking or inhaling fumes from synthetic cannabinoids. The Georgia Poison Center notified the Georgia Drug and Narcotics Agency, which informed the Georgia Department of Public Health (DPH). The Brunswick emergency department was asked to report any additional patients who reported use of synthetic cannabinoid to the Coastal District Health Department. DPH investigators reviewed recent medical records of patients who had gone to the emergency department and found that 22 patients had been examined after using synthetic cannabinoids during August 22–September 9, 2013.
The 22 patients were aged 16–57 years (median: 25 years); 18 (82%) were male. Patients experienced hyperglycemia (13 [59%]), hypokalemia (nine [41%]), acidosis (seven [32%]), tachycardia (13 [59%]), nausea/vomiting (eight [36%]), confusion/disorientation (seven [32%]), aggression (seven [32%]), somnolence/unresponsiveness (seven [32%]), and seizures (three [14%]). Complications included pneumonia (two patients), rhabdomyolysis (one), and myocardial infarction (one). Six (27%) patients were admitted to the intensive care unit; five (23%) required assisted ventilation; none died. Serum from seven of the initial eight patients was tested for synthetic cannabinoid by the Clinical and Environmental Toxicology Laboratory at the University of California, San Francisco. Five tested positive for ADB-PINACA (N-(1-amino-3,3-dimethy-1-oxobutan-2-yl)-1-pentyl-1H-indazole-3-carboxamide), a previously unrecognized synthetic cannabinoid related to indole compounds recently identified in Europe and Japan (1).
Law enforcement authorities removed the synthetic cannabinoid from the implicated Brunswick smoke shop,* which sold all types of tobacco products and smoking paraphernalia. The product, “Crazy Clown,” was tested by the Georgia Bureau of Investigation Crime Laboratory, which identified ADB-PINACA, an indazole classified under Georgia law as Schedule 1 on the basis of its close relationship to Schedule 1 compounds already specified. The smoke shop owners were charged on September 10, 2013, with possession of a Schedule 1 controlled substance with intent to distribute; no additional patients who used synthetic cannabinoids have been reported by the ED.
Synthetic cannabinoids are designer drugs often smoked as a marijuana alternative. Despite laws prohibiting synthetic cannabinoid sales, they are still widely available, and recent increases in reports of synthetic cannabinoid use and adverse health effects have occurred (2,3). Common adverse effects include altered mental status and tachycardia. Clinicians examining patients with suspected drug abuse and these symptoms should consider synthetic cannabinoid intoxication (4). Public health authorities can raise awareness of adverse events associated with synthetic cannabinoids and establish mechanisms for surveillance by partnering with poison centers, health-care providers, and law enforcement.
Uchiyama N, Kawamura M, Kikura-Hanajiri R, et al. Identification of two new-type synthetic cannabinoids, N-(1-adamantyl)-1-pentyl-1H-indole-3-carboxamide (APICA) and N-(1-adamantyl)-1-pentyl-1H-indazole-3-carboxamide (APINACA), and detection of five synthetic cannabinoids, AM-1220, AM-2233, AM-1241, CB-13 (CRA-13), and AM-1248, as designer drugs in illegal products. Forensic Toxicol 2012;30:114–25.
Fattore L, Fratta W. Beyond THC: the new generation of cannabinoid designer drugs. Front Behav Neurosci 2011;5:60.
Sex-Specific Chest Pain Characteristics in the Early Diagnosis of Acute Myocardial Infarction
Maria Rubini Gimenez, MD1,2; Miriam Reiter, MD1; Raphael Twerenbold, MD1,3; Tobias Reichlin, MD1,4; Karin Wildi, MD1,5; Philip Haaf, MD1; Katharina Wicki, MD1; Christa Zellweger, MD1,5; Rebeca Hoeller, MD1,5; Berit Moehring, MD1,5; Seoung Mann Sou, MD1,5; Mira Mueller, MD1; Kris Denhaerynck, PhD1; Bernadette Meller, MD1; Fabio Stallone, MD1; Sarah Henseler, MD1; Stefano Bassetti, MD6; Nicolas Geigy, MD7; Stefan Osswald, MD1; Christian Mueller, MD1
JAMA Intern Med. Published online November 25, 2013. doi:10.1001/jamainternmed.2013.12199
“……….. Acute myocardial infarction was the adjudicated final diagnosis in 143 women (18.0%) and 369 men (22.0%). Although most CPCs were reported with similar frequency in women and men, several CPCs were reported more frequently in women (P < .05). The accuracy of most CPCs in the diagnosis of AMI was low in women and men, with likelihood ratios close to 1. Thirty-one of 34 CPCs (91.2%) showed similar likelihood ratios for the diagnosis of AMI in women and men, and only 3 CPCs (8.8%) seemed to have a sex-specific diagnostic performance with P < .05 for interaction. These CPCs were related to pain duration (2-30 and >30 minutes) and dynamics (decreasing pain intensity). However, because their likelihood ratios were close to 1, the 3 CPCs did not seem clinically helpful. Similar results were obtained when examining combinations of CPCs (all interactions, P ≥ .05)……..”
BP therapy didn’t boost survival in ischemic stroke
By: MITCHEL L. ZOLER
DALLAS – “Immediate blood pressure reduction in hypertensive acute ischemic stroke patients did not reduce death and disability after 14 days, but the strategy was safe and did not worsen patient’s 14-day outcomes, a randomized controlled study has shown.
The findings suggest that, among patients with relatively mild acute ischemic strokes and a systolic blood pressure of 140-219 mm Hg, “the decision to lower blood pressure with antihypertensive treatment should be based on individual clinical judgment,” Dr. Jiang He said at the American Heart Association scientific sessions…………..”
Int J Emerg Med. 2013 Oct 1;6(1):35. [Epub ahead of print]
Emergency department waiting room: many requests, many insured and many primary care physician referrals.
Kamali MF, Jain M, Jain AR, Schneider SM.
Contrary to popular belief, at our ED a large proportion of low-acuity patients has a PCP and is medically insured. Providing patients with appropriate reasons for the wait, an accurate estimate of waiting time and creating separate areas to examine minor illness/injuries would increase patient satisfaction within our population subset
“……….Among ICU patients with hypovolemia, the use of colloids vs crystalloids did not result in a significant difference in 28-day mortality. Although 90-day mortality was lower among patients receiving colloids, this finding should be considered exploratory and requires further study before reaching conclusions about efficacy.”
Urinalysis is an Inadequate Screen for Rhabdomyolysis
Published online: 06 November 2013
Sameir A. Alhadi, Rawnica Ruegner, Brandy Snowden, Gregory W. Hendey
American Journal of Emergency Medicine
“…….During the study period, 1,796 patients were diagnosed with rhabdomyolysis, of whom 228 met inclusion criteria. The mean peak CPK was 27,509 IU/L. One hundred and ninety five (86%) had a urine dip positive for blood. However, only 94 (41%) patients had a positive urine dip and negative microscopic hematuria, resulting in a sensitivity of 41% (95% CI, 35%-47%). In a subset of 66 (29%) patients with more severe rhabdomyolysis (initial CPK > 10,000 IU/L; mean CPK 53,365 IU/L), UA had a sensitivity of 55% (95% CI, 43%-67%). Broadening the definition of negative microscopy from 0-3 RBCs to less than 10 RBCs only increased the sensitivity to 79% (95% CI, 73%-83%)…….
The combination of a positive urine dip for blood and negative microscopy is an insensitive test for rhabdomyolysis and the absence of this finding should not be used to exclude the diagnosis.”
NIH launches trial of investigational genital herpes vaccine
Researchers have launched an early-stage clinical trial of an investigational vaccine designed to prevent genital herpes disease. The National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health, is sponsoring the Phase I trial, which is being conducted at the NIH Clinical Center in Bethesda, Md.
Genital herpes is one of the most common sexually transmitted infections in the United States. Most genital herpes cases are caused by infection with herpes simplex virus type 2 (HSV-2); however, herpes simplex virus type 1 (HSV-1) can also cause genital herpes. An estimated 776,000 people in the United States are infected with HSV-2 or HSV-1 each year. There is no vaccine to prevent genital herpes.
“Although genital herpes is treatable, it is a lifelong infection that can exact a substantial psychological and physical toll on infected individuals and places them at higher risk of acquiring HIV,” said NIAID Director Anthony S. Fauci, M.D. “Furthermore, mothers with active genital herpes infection at time of delivery can transmit the virus to their newborns, which can lead to severe illness and death.”
“A protective vaccine would help to reduce significantly the spread of this all-too- common sexually transmitted infection,” Fauci added.
Led by principal investigator Lesia K. Dropulic, M.D., of NIAID’s Laboratory of Infectious Diseases, the trial will test an investigational HSV-2 vaccine candidate, called HSV529, for safety and the ability to generate an immune system response. The investigational vaccine manufactured by Sanofi Pasteur was developed by David Knipe, Ph.D., professor of microbiology and immunobiology at Harvard Medical School, Boston.
Preclinical testing of the candidate vaccine involved a 10-year collaborative effort between Dr. Knipe and Jeffrey Cohen, M.D., chief of NIAID’s Laboratory of Infectious Diseases. The experimental product is a replication-defective vaccine, meaning that scientists have removed two key proteins from the vaccine virus so that it cannot multiply to cause genital herpes.
The clinical trial is expected to enroll 60 adults ages 18 to 40, who will be divided into three groups of 20 participants each. The first group will be of people who have been previously infected with HSV-2 and HSV-1 or solely with HSV-2; the second will have individuals who had been infected with HSV-1 only; and the third will consist of those who have not been infected with HSV-1 or HSV-2. The investigational vaccine is being tested among study participants who have previously been infected with HSV to determine if it may pose any safety issues.
Within each of the three groups, researchers will randomly assign participants to receive three doses (0.5 milliliters each) of the investigational HSV529 vaccine (15 participants) or a saline-based placebo vaccine (five participants). The three vaccinations will occur at study enrollment and again one month and six months later. Participant safety will be monitored throughout the course of the trial, and researchers will follow participants for six months after they have received their last dose of vaccine. Blood samples will be used to evaluate the candidate vaccine’s ability to stimulate immune system responses to HSV-2, including production of virus-specific antibodies and T-cell responses. The study is expected to be completed by October 2016.
HSV-2 is generally transmitted through sexual contact and can spread even when the infected individual shows no symptoms. Although HSV-1 commonly infects the mouth and lips, it can also cause genital herpes. Once in the body, HSV migrates to nerve cells and remains there permanently, where it can reactivate to cause painful sores and blisters.
NIAID conducts and supports research—at NIH, throughout the United States, and worldwide—to study the causes of infectious and immune-mediated diseases, and to develop better means of preventing, diagnosing and treating these illnesses. News releases, fact sheets and other NIAID-related materials are available on the NIAID Web site at http://www.niaid.nih.gov.
About the National Institutes of Health (NIH): NIH, the nation’s medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit www.nih.gov.
Low Molecular Weight Heparins: Drug Safety Communication – Recommendations to Decrease Risk of Spinal Column Bleeding and Paralysis
AUDIENCE: Pharmacy, Cardiology, Anesthesiology
ISSUE: The U.S. Food and Drug Administration (FDA) is recommending that health care professionals carefully consider the timing of spinal catheter placement and removal in patients taking anticoagulant drugs, such as enoxaparin, and delay dosing of anticoagulant medications for some time interval after catheter removal to decrease the risk of spinal column bleeding and subsequent paralysis after spinal injections, including epidural procedures and lumbar punctures. These new timing recommendations, which can decrease the risk of epidural or spinal hematoma, will be added to the labels of anticoagulant drugs known as low molecular weight heparins, including Lovenox and generic enoxaparin products and similar products.
BACKGROUND: Epidural or spinal hematomas are a known risk of enoxaparin in the setting of spinal procedures and are already described in the Boxed Warning and the Warnings and Precautions sections of the labels for Lovenox and generic enoxaparin products. However, these serious adverse events continue to occur (see Data Summary). To address this safety concern, FDA worked with the manufacturer of Lovenox, Sanofi-Aventis, to further evaluate this risk and to update the Warnings and Precautions section of the Lovenox label with these additional timing recommendations. The labels for generic enoxaparin products will also be revised accordingly, as will those of other low molecular weight heparin-type products.
It is important to note that all anticoagulants carry the risk of causing spinal bleeding when used in conjunction with epidural/spinal anesthesia or spinal puncture. We are continuing to evaluate the safety of other anticoagulants to determine if additional label changes are needed.
RECOMMENDATION: Health care professionals and institutions involved in performing spinal/epidural anesthesia or spinal punctures should determine, as part of a preprocedure checklist, whether a patient is receiving anticoagulants and identify the appropriate timing of enoxaparin dosing in relation to catheter placement or removal. To reduce the potential risk of bleeding, consider both the dose and the elimination half-life of the anticoagulant:
For enoxaparin, placement or removal of a spinal catheter should be delayed for at least 12 hours after administration of prophylactic doses such as those used for prevention of deep vein thrombosis. Longer delays (24 hours) are appropriate to consider for patients receiving higher therapeutic doses of enoxaparin (1 mg/kg twice daily or 1.5 mg/kg once daily).
A postprocedure dose of enoxaparin should usually be given no sooner than 4 hours after catheter removal.
In all cases, a benefit-risk assessment should consider both the risk for thrombosis and the risk for bleeding in the context of the procedure and patient risk factors.
“…..AF is independently associated with an increased risk of incident MI, especially in women and blacks. These findings add to the growing concerns of the seriousness of AF as a public health burden: in addition to being a well-known risk factor for stroke, AF is also associated with increased risk of MI…….”
Bay Pines VA hospital emergency room doctor shielded couple from bullets
6:08 PM, Oct 28, 2013
St. Petersburg, Florida - ”A Vietnam veteran and his wife were just feet away from a shooting inside Bay Pines VA hospital in St. Petersburg Friday when they say a doctor put his own life in danger to save theirs.
Sam Brooks is retired Navy. He risked his life for our country. The military hero who’s a Vietnam vet can’t believe an E.R. doctor someone he’d never even met before would risk his life to save him and his wife………..”