California Poison Control System Implementation of a Novel Hotline to Treat Patients with Opioid Use Disorder.

INTRODUCTION: In response to the opioid epidemic, California state officials sought to fund a variety of projects aimed at reducing opioid-related deaths. We describe the California Poison Control System's (CPCS) successful effort in integrating itself into the state's public health response to the opioid epidemic and describe poison control center staff attitudes and perceptions regarding the role of poison control centers at treating opioid withdrawal and addiction. METHODS: The CPCS created a leadership team and a separate 24/7 hotline, called the CPCS-Bridge line, to field calls from frontline health care providers interested in initiating medications for opioid use disorder for their patients. The implementation process also included training of all CPCS staff. In addition, the leadership team conducted an anonymous survey study to analyze attitudes and perceptions of poison center staff on the role of the poison center in the management of opioid use disorder. Descriptive statistics were used to characterize the data. RESULTS: Calls to the new hotline increased over time, along with CPCS-initiated outreach and advertisement. A majority of questions received by the hotline were related to uncomplicated buprenorphine starts in special populations. A pre-training survey was completed by 27 (58%) of CPCS specialists, many of whom had no prior experience treating patients with opioid use disorder. Only one specialist (2%) did not believe that poison centers should play a role in opioid addiction. CONCLUSIONS: The California Poison Control System successfully created a hotline to assist frontline health care providers in treating patients with opioid use disorder and highlight the critical role of poison centers in the public health domain. Increased federal funding to poison centers is likely to be mutually beneficial to all parties involved.

Cannabis Intoxication Case Series: The Dangers of Edibles Containing Tetrahydrocannabinol.

STUDY OBJECTIVE: Cannabis and its principal active constituent, Δ9-tetrahydrocannabinol (THC), are increasingly available as edibles resembling commercially available food products. In this case series, we describe a population of predominantly pediatric patients who were inadvertently exposed to a THC-containing product in San Francisco. METHODS: Twelve children and 9 adults were identified, with 16 patients having detectable serum THC and THC metabolites. All patients presented to hospitals with a variety of constitutional symptoms and all were discharged home within 12 hours. RESULTS: In general, pediatric patients had more severe symptoms and longer hospital length of stay, and, uniquely, a majority presented with leukocytosis and elevated lactic acid levels. CONCLUSION: We recommend that efforts be made to increase general public awareness in regard to the potential hazards of THC-containing edibles resembling commercially available food products.

Comparative Toxicity of Tapentadol and Tramadol Utilizing Data Reported to the National Poison Data System.

BACKGROUND: Tapentadol (TAP) and tramadol (TRA) provide pain relief through similar monoaminergic and opioid agonist properties. OBJECTIVE: To compare clinical effects and medical outcomes between TAP and TRA exposures reported to the National Poison Data System of the American Association of Poison Control Centers. METHODS: A retrospective cohort study was conducted analyzing national data for single medication TAP or TRA cases reported from June 2009 through December 2011. Case outcomes, dichotomized as severe versus mild; clinical effects; and use of naloxone were compared. RESULTS: There were 217 TAP and 8566 TRA cases. Significantly more severe outcomes were associated with TAP exposures for an all-age comparison (relative risk [RR] = 1.24; 95% CI = 1.04-1.48), and for the <6-year-old age group (RR = 5.76; 95% CI = 2.20-15.11). Patients with TAP exposures had significantly greater risk of respiratory depression (RR = 5.56; 95% CI = 3.50-8.81), coma (RR = 4.16; 95% CI = 2.33-7.42), drowsiness/lethargy (RR = 1.38; 95% CI = 1.15-1.66), slurred speech (RR = 3.51; 95% CI = 1.98-6.23), hallucination/delusion (RR = 7.25; 95% CI = 3.61-14.57), confusion (RR = 2.54; 95% CI = 1.56-4.13) and use of naloxone (RR = 3.80; 95% CI = 2.96-4.88). TRA exposures had significantly greater risk of seizures (RR = 7.94; 95% CI = 2.99-20.91) and vomiting (RR = 1.96; 95% CI = 1.07-3.60). CONCLUSION: TAP was associated with significantly more toxic clinical effects and severe outcomes consistent with an opioid agonist. TRA was associated with significantly higher rates of seizures and vomiting.

Phenelzine-induced myocardial injury: a case report.

INTRODUCTION: Phenelzine is an irreversible monoamine oxidase inhibitor (MAOI). Hypertensive reactions after ingestion of tyramine-rich foods such as cheese are well known. However, a review of the available medical literature found no previous reports of myocardial infarction resulting from the ingestion of cheese by a patient taking a MAOI. CASE REPORT: A 34-year-old female taking phenelzine for depression developed severe chest pain 1 h after eating cheese. She was hypertensive and the electrocardiography showed ischemic changes in the antero-lateral chest leads. The chest pain and elevated blood pressure were relieved with intravenous morphine and nitroprusside. The initial serum troponin I level was normal, but serial repeat levels showed a rising trend with a peak at 4.89 ug/L (reference range <0.05 ug/L) 6 h after the initial blood draw, suggestive of a non-ST elevation myocardial infarction. The patient subsequently developed hypotension 4 h after another therapeutic dose of phenelzine was served to the patient 4 h after her admission to the ED. This was corrected with at least 2 L of intravenous normal saline boluses. Subsequent EKGs and Sestamibi scan showed no evidence of cardiac ischemia. She was discharged home after a hospital stay of 3 days. DISCUSSION: We believe this to be the first reported case of myocardial infarction resulting from ingestion of cheese in a patient taking a MAOI. It might be expected that hypertensive crisis could lead to a myocardial infarction, but a review of the medical literature found no such cases reported.

High-valent nonheme iron. Two distinct iron(IV) species derived from a common iron(II) precursor.

The reaction of [Fe(II)(beta-BPMCN)(OTf)2] (1, BPMCN = N,N'-bis(2-pyridylmethyl)-N,N'-dimethyl-trans-1,2-diaminocyclohexane) with tBuOOH at low-temperature yields alkylperoxoiron(III) intermediates 2 in CH2Cl2 and 2-NCMe in CH3CN. At -45 degrees C and above, 2-NCMe converts to a pale green species 3 (lambda(max) = 753 nm, epsilon = 280 M(-1) cm(-1)) in 90% yield, identified as [Fe(IV)(O)(BPMCN)(NCCH3)]2+ by comparison to other nonheme [Fe(IV)(O)(L)]2+ complexes. Below -55 degrees C in CH2Cl2, 2 decays instead to form deep turquoise 4 (lambda(max) = 656, 845 nm; epsilon = 4000, 3600 M(-1) cm(-1)), formulated to be an unprecedented alkylperoxoiron(IV) complex [Fe(IV)(BPMCN)(OH)(OOtBu)]2+ on the basis of Mössbauer, EXAFS, resonance Raman, NMR, and mass spectral evidence. The reactivity of 1 with tBuOOH in the two solvents reveals an unexpectedly rich iron(IV) chemistry that can be supported by the BPMCN ligand.

The reaction of [FeII(tpa)] with H2O2 in acetonitrile and acetone--distinct intermediates and yet similar catalysis.

The reaction of [FeII(tpa)(OTf)2] (tpa=tris(2-pyridylmethyl)amine) and its related 5-Me3-tpa complex with hydrogen peroxide affords spectroscopically distinct iron(III)-peroxo intermediates in CH3CN and acetone. The reaction in acetonitrile at -40 degrees C results in the formation of the previously reported Fe(III)-OOH intermediate, the end-on hydroperoxo coordination mode of which is established in this paper by detailed resonance Raman isotope-labeling experiments. On the other hand, the reaction in acetone below -40 degrees C leads to the observation of a different peroxo intermediate identified by resonance Raman spectroscopy to be an FeIII-OOC (CH3)2OH species; this represents the first example of an intermediate derived from the adduct of H2O2 and acetone. The peroxoacetone intermediate decays more rapidly than the corresponding FeIII-OOH species and converts to an FeIV=O species by O-O bond homolysis. This decay process is analogous to that observed for [FeIII(tpa)(OOtBu)]2+ and in fact exhibits a comparable enthalpy of activation of 54(3) kJ mol(-1). Thus, with respect to their physical properties at low temperature, the peroxoacetone intermediate resembles [FeIII(tpa)(OOtBu)]2+ more than the corresponding FeIII-OOH species. At room temperature, however, the behavior of the Fe(tpa)/H2O2 combination in acetone in catalytic hydrocarbon oxidations differs significantly from that of the Fe(tpa)/tBuOOH combination and more closely matches that of the Fe(tpa)/H2O2 combination in CH3CN. Like the latter, the Fe(tpa)/H2O2 combination in acetone catalyzes the hydroxylation of cis-1,2-dimethylcyclohexane to its tertiary alcohol with high stereoselectivity and carries out the epoxidation and cis-dihydroxylation of olefins. These results demonstrate the subtle complexity of the Fe(tpa)/H2O2 reaction surface.

End-on and side-on peroxo derivatives of non-heme iron complexes with pentadentate ligands: models for putative intermediates in biological iron/dioxygen chemistry.

Mononuclear iron(III) species with end-on and side-on peroxide have been proposed or identified in the catalytic cycles of the antitumor drug bleomycin and a variety of enzymes, such as cytochrome P450 and Rieske dioxygenases. Only recently have biomimetic analogues of such reactive species been generated and characterized at low temperatures. We report the synthesis and characterization of a series of iron(II) complexes with pentadentate N5 ligands that react with H(2)O(2) to generate transient low-spin Fe(III)-OOH intermediates. These intermediates have low-spin iron(III) centers exhibiting hydroperoxo-to-iron(III) charge-transfer bands in the 500-600-nm region. Their resonance Raman frequencies, nu(O)(-)(O), near 800 cm(-)(1) are significantly lower than those observed for high-spin counterparts. The hydroperoxo-to-iron(III) charge-transfer transition blue-shifts and the nu(O)(-)(O) of the Fe-OOH unit decreases as the N5 ligand becomes more electron donating. Thus, increasing electron density at the low-spin Fe(III) center weakens the O-O bond, in accord with conclusions drawn from published DFT calculations. The parent [(N4Py)Fe(III)(eta(1)-OOH)](2+) (1a) ion in this series (N4Py = N,N-bis(2-pyridylmethyl)-N-bis(2-pyridyl)methylamine) can be converted to its conjugate base, which is demonstrated to be a high-spin iron(III) complex with a side-on peroxo ligand, [(N4Py)Fe(III)(eta(2)-O(2))](+) (1b). A detailed analysis of 1a and 1b by EPR and Mössbauer spectroscopy provides insights into their electronic properties. The orientation of the observed (57)Fe A-tensor of 1a can be explained with the frequently employed Griffith model provided the rhombic component of the ligand field, determined by the disposition of the hydroperoxo ligand, is 45 degrees rotated relative to the octahedral field. EXAFS studies of 1a and 1b reveal the first metrical details of the iron-peroxo units in this family of complexes: [(N4Py)Fe(III)(eta(1)-OOH)](2+) has an Fe-O bond of 1.76 A, while [(N4Py)Fe(III)(eta(2)-O(2))](+) has two Fe-O bonds of 1.93 A, values which are in very good agreement with results obtained from DFT calculations.

An FeIV=O complex of a tetradentate tripodal nonheme ligand.

The reaction of [Fe(II)(tris(2-pyridylmethyl)amine, TPA)(NCCH(3))(2)](2+) with 1 equiv. peracetic acid in CH(3)CN at -40 degrees C results in the nearly quantitative formation of a pale green intermediate with lambda(max) at 724 nm ( epsilon approximately 300 M(-1).cm(-1)) formulated as [Fe(IV)(O)(TPA)](2+) by a combination of spectroscopic techniques. Its electrospray mass spectrum shows a prominent feature at mz 461, corresponding to the [Fe(IV)(O)(TPA)(ClO(4))](+) ion. The Mössbauer spectra recorded in zero field reveal a doublet with DeltaE(Q) = 0.92(2) mms and delta = 0.01(2) mms; analysis of spectra obtained in strong magnetic fields yields parameters characteristic of S = 1 Fe(IV)O complexes. The presence of an Fe(IV)O unit is also indicated in its Fe K-edge x-ray absorption spectrum by an intense 1-s --> 3-d transition and the requirement for an ON scatterer at 1.67 A to fit the extended x-ray absorption fine structure region. The [Fe(IV)(O)(TPA)](2+) intermediate is stable at -40 degrees C for several days but decays quantitatively on warming to [Fe(2)(mu-O)(mu-OAc)(TPA)(2)](3+). Addition of thioanisole or cyclooctene at -40 degrees C results in the formation of thioanisole oxide (100% yield) or cyclooctene oxide (30% yield), respectively; thus [Fe(IV)(O)(TPA)](2+) is an effective oxygen-atom transfer agent. It is proposed that the Fe(IV)O species derives from OO bond heterolysis of an unobserved Fe(II)(TPA)-acyl peroxide complex. The characterization of [Fe(IV)(O)(TPA)](2+) as having a reactive terminal Fe(IV)O unit in a nonheme ligand environment lends credence to the proposed participation of analogous species in the oxygen activation mechanisms of many mononuclear nonheme iron enzymes.

O2- and alpha-ketoglutarate-dependent tyrosyl radical formation in TauD, an alpha-keto acid-dependent non-heme iron dioxygenase.

Taurine/alpha-ketoglutarate dioxygenase (TauD), a non-heme mononuclear Fe(II) oxygenase, liberates sulfite from taurine in a reaction that requires the oxidative decarboxylation of alpha-ketoglutarate (alphaKG). The lilac-colored alphaKG-Fe(II)TauD complex (lambda(max) = 530 nm; epsilon(530) = 140 M(-)(1) x cm(-)(1)) reacts with O(2) in the absence of added taurine to generate a transient yellow species (lambda(max) = 408 nm, minimum of 1,600 M(-)(1) x cm(-)(1)), with apparent first-order rate constants for formation and decay of approximately 0.25 s(-)(1) and approximately 0.5 min(-)(1), that transforms to yield a greenish brown chromophore (lambda(max) = 550 nm, 700 M(-)(1) x cm(-)(1)). The latter feature exhibits resonance Raman vibrations consistent with an Fe(III) catecholate species presumed to arise from enzymatic self-hydroxylation of a tyrosine residue. Significantly, (18)O labeling studies reveal that the added oxygen atom derives from solvent rather than from O(2). The transient yellow species, identified as a tyrosyl radical on the basis of EPR studies, is formed after alphaKG decomposition. Substitution of two active site tyrosine residues (Tyr73 and Tyr256) by site-directed mutagenesis identified Tyr73 as the likely site of formation of both the tyrosyl radical and the catechol-associated chromophore. The involvement of the tyrosyl radical in catalysis is excluded on the basis of the observed activity of the enzyme variants. We suggest that the Fe(IV) oxo species generally proposed (but not yet observed) as an intermediate for this family of enzymes reacts with Tyr73 when substrate is absent to generate Fe(III) hydroxide (capable of exchanging with solvent) and the tyrosyl radical, with the latter species participating in a multistep TauD self-hydroxylation reaction.

Electronic structure and reactivity of low-spin Fe(III)-hydroperoxo complexes: comparison to activated bleomycin.

The spectroscopic properties, electronic structure, and reactivity of the low-spin Fe(III)-hydroperoxo complex [Fe(N4Py)(OOH)](2+) (1, N4Py = N,N-bis(2-pyridylmethyl)-N-bis(2-pyridyl)methylamine) are investigated in comparison to those of activated bleomycin (ABLM). Complex 1 is characterized by Raman features at 632 (Fe-O stretch) and 790 cm(-1) (O-O stretch), corresponding to a strong Fe-O bond (force constant 3.62 mdyn/A) and a weak O-O bond (3.05 mdyn/A). The UV-vis spectrum of 1 shows a broad absorption band around 550 nm that is assigned to a charge-transfer transition from the hydroperoxo to a t(2g) d orbital of Fe(III) using resonance Raman and MCD spectroscopies and density functional (DFT) calculations. Compared to low-spin [Fe(TPA)(OH(x))(OO(t)Bu)](x+)(TPA = tris(2-pyridylmethyl)amine, x = 1 or 2), an overall similar Fe-OOR bonding results for low-spin Fe(III)-alkylperoxo and -hydroperoxo species. Correspondingly, both systems show similar reactivities and undergo homolytic cleavage of the O-O bond. From the DFT calculations, this reaction is more endothermic for 1 due to the reduced stabilization of the .OH radical compared to .O(t)Bu and the absence of the hydroxo ligand that helps to stabilize the resulting Fe(IV)=O species. In contrast, ABLM has a somewhat different electronic structure where no pi donor bond between the hydroperoxo ligand and iron(III) is present [Neese, F.; Zaleski, J. M.; Loeb-Zaleski, K.; Solomon, E. I. J. Am. Chem. Soc. 2000, 122, 11703]. Possible reaction pathways for ABLM are discussed in relation to known experimental results.

Sulfide oxidation by hydrogen peroxide catalyzed by iron complexes: two metal centers are better than one.

Peroxoiron species have been proposed to be involved in catalytic cycles of iron-dependent oxygenases and in some cases as the active intermediates during oxygen-transfer reactions. The catalytic properties of a mononuclear iron complex, [Fe(II)(pb)(2)(CH(3)CN)(2)] (pb=(-)4,5-pinene-2,2'-bipyridine), have been compared to those of its related dinuclear analogue. Each system generates specific peroxo adducts, which are responsible for the oxidation of sulfides to sulfoxides. The dinuclear catalyst was found to be more reactive and (enantio)selective than its mononuclear counterpart, suggesting that a second metal site affords specific advantages for stereoselective catalysis. These results might help for the design of future enantioselective iron catalysts.

Enantioselective Sulfoxidation as a Probe for a Metal-Based Mechanism in H(2)O(2)-Dependent Oxidations Catalyzed by a Diiron Complex.

The catalytic properties of the diiron complex 1, Fe(2)OL(4)(H(2)O)(2)(ClO(4))(4) with L = (-)-4,5-pinenebipyridine, a chiral bipyridine derivative, have been investigated. Complex 1 efficiently catalyzes the oxidation of aryl sulfides to the corresponding sulfoxides by hydrogen peroxide, with yields ranging from 45 to 90% based on the oxidant. Furthermore the reactions were enantioselective and produced a mixture of sulfoxide enantiomers with significant enantiomeric excesses. The largest ee value (40%) was found in the case of p-bromophenyl methyl sulfide. Optimal ee's were obtained in polar solvents and at low temperature (below 0 degrees C), when the excess of the oxidant was limited. The observation of (i) a saturation kinetics with respect to both sulfide and H(2)O(2) concentrations, (ii) a linear Hammett correlation of the initial V(max) values with sigma(p) values, for a series of p-substituted aryl methyl sulfides, (iii) iron-peroxo complexes, characterized by light absorption and Raman resonance spectroscopies, during reaction of complex 1 with H(2)O(2), and (iv) a saturation kinetics with respect to sulfide during oxidation of sulfide into sulfoxide by the iron-peroxo complexes led us to propose that the iron-peroxo moiety is the actual oxygen atom donor to the substrate, thus explaining the enantioselective control of the catalytic reaction. These data demonstrate that oxidations by non heme diiron complexes can proceed through metal-based pathways and can thus be made stereoselective.

Iron Chemistry of a Pentadentate Ligand That Generates a Metastable Fe(III)-OOH Intermediate.

In an effort to gain more insight into the factors controlling the formation of low-spin non-heme Fe(III)-peroxo intermediates in oxidation catalysis, such as activated bleomycin, we have synthesized a series of iron complexes based on the pentadentate ligand N4Py (N4Py = N,N-bis(2-pyridylmethyl)-N-(bis-2-pyridylmethyl)amine). The following complexes have been prepared: [(N4Py)Fe(II)(CH(3)CN)](ClO(4))(2) (1), [(N4Py)Fe(II)Cl](ClO(4)) (2), [(N4Py)Fe(III)OMe](ClO(4))(2) (3), and [(N4Py)(2)Fe(2)O](ClO(4))(4) (4). Complexes 1 and 2 have low- and high-spin Fe(II) centers, respectively, whereas 3 is an Fe(III) complex that undergoes a temperature-dependent spin transition. The iron centers in the oxo-bridged dimer 4 are antiferromagnetically coupled (J = -104 cm(-)(1)). Comparison of the crystal structures of 1, 3, and 4 shows that the ligand is well suited to accommodate both Fe(II) and Fe(III) in either spin state. For the high-spin Fe(III) complexes 3 and 4 the iron atoms are positioned somewhat outside of the cavity formed by the ligand, while in the case of the low-spin Fe(II) complex 1 the iron atom is retained in the middle of the cavity with approximately equal bond lengths to all nitrogen atoms from the ligand. On the basis of UV/vis and EPR observations, it is shown that 1, 3, and 4 all react with H(2)O(2) to generate the purple low-spin [(N4Py)Fe(III)OOH](2+) intermediate (6). In the case of 1, titration experiments with H(2)O(2) monitored by UV/vis and (1)H NMR reveal the formation of [(N4Py)Fe(III)OH](2+) (5) and the oxo-bridged diiron(III) dimer (4) prior to the generation of the Fe(III)-OOH species (6). Raman spectra of 6 show distinctive Raman features, particularly a nu(O-O) at 790 cm(-)(1) that is the lowest observed for any iron-peroxo species. This observation may rationalize the reactivity of low-spin Fe(III)-OOH species such as "activated bleomycin".

Metal Complex-Catalyzed Epoxidation of Olefins by Dioxygen with Co-Oxidation of Aldehydes. A Mechanistic Study.

Mechanistic studies of the oxidation of olefins by dioxygen plus aldehyde in the presence of metal complexes such as metalloporphyrins and metal cyclam complexes have been carried out. Epoxides were the predominant products, with trace amounts of allylic oxidation products. cis-Stilbene was oxidized to a mixture of cis- and trans-stilbene oxides. It is concluded from this study that the principal role of the metal complexes is to aid in the initiation step for the free radical autoxidation of the aldehyde and that acylperoxy radicals generated in the autoxidation reaction (or metal complexes formed by complexation of the acylperoxy radicals) are the active epoxidizing agents.