Clinical Presentations of Bupropion Prescription Drug Misuse: A Systematic Review.

BACKGROUND: Among prescribers, bupropion is considered a substance of low misuse potential, with some studies showing lesser misuse potential than caffeine. However, several case reports exist of recreational bupropion misuse and diversion. Our goal is to understand at-risk populations, clinical courses, interventions, and outcomes after acute ingestion of bupropion via oral, intravenous route, and insufflation. METHODS: The systematic review was registered with PROSPERO on August 5, 2023. We conducted a systematic literature search on July 30, 2023, utilizing 8 databases with the help of the Medical Subject Headings (MeSH) term "Bupropion" in the context of misuse and abuse. Ultimately, we found 17 articles with qualitative synthesis relevant to our study objective and meeting our inclusion/exclusion criteria. RESULTS: Bupropion insufflation and intravenous injection occur almost exclusively in patients with a substance use disorder history, with a preponderance of patients with stimulant use disorder or multiple substance use disorders. Additionally, many were dual-diagnosis patients with a history of attention deficit hyperactivity disorder and stimulant use disorder, treated with bupropion. Patients describe the effects of bupropion insufflation/IV injection as a milder "cocaine-like" high that is brief, with less severe withdrawal effects of anxiety and agitation. The most common side effect at presentation was tachycardia, followed by seizures responsive to IV benzodiazepines. IV injection seems particularly insulting to the vascular system, with cellulitis, tissue necrosis, and digital ischemia as documented adverse effects. CONCLUSIONS: This systematic review highlights the bupropion misuse potential in certain patient populations and serves to increase awareness among clinicians. Additional patient screening, monitoring and follow-up, surveillance, and further research are needed to investigate and prevent bupropion misuse in at-risk patient populations entirely.

Biological activities of meroterpenoids isolated from different sources.

Meroterpenoids are natural products synthesized by unicellular organisms such as bacteria and multicellular organisms such as fungi, plants, and animals, including those of marine origin. Structurally, these compounds exhibit a wide diversity depending upon the origin and the biosynthetic pathway they emerge from. This diversity in structural features imparts a wide spectrum of biological activity to meroterpenoids. Based on the biosynthetic pathway of origin, these compounds are either polyketide-terpenoids or non-polyketide terpenoids. The recent surge of interest in meroterpenoids has led to a systematic screening of these compounds for many biological actions. Different meroterpenoids have been recorded for a broad range of operations, such as anti-cholinesterase, COX-2 inhibitory, anti-leishmanial, anti-diabetic, anti-oxidative, anti-inflammatory, anti-neoplastic, anti-bacterial, antimalarial, anti-viral, anti-obesity, and insecticidal activity. Meroterpenoids also possess inhibitory activity against the expression of nitric oxide, TNF- α, and other inflammatory mediators. These compounds also show renal protective, cardioprotective, and neuroprotective activities. The present review includes literature from 1999 to date and discusses 590 biologically active meroterpenoids, of which 231 are from fungal sources, 212 are from various species of plants, and 147 are from marine sources such as algae and sponges.

Full-face motorcycle helmets to reduce injury and death: A systematic review, meta-analysis, and practice management guideline from the Eastern Association for the Surgery of Trauma.

BACKGROUND: While motorcycle helmets reduce mortality and morbidity, no guidelines specify which is safest. We sought to determine if full-face helmets reduce injury and death. METHODS: We searched for studies without exclusion based on: age, language, date, or randomization. Case reports, professional riders, and studies without original data were excluded. Pooled results were reported as OR (95% CI). Risk of bias and certainty was assessed. (PROSPERO #CRD42021226929). RESULTS: Of 4431 studies identified, 3074 were duplicates, leaving 1357 that were screened. Eighty-one full texts were assessed for eligibility, with 37 studies (n = 37,233) eventually included. Full-face helmets reduced traumatic brain injury (OR 0.40 [0.23-0.70]); injury severity for the head and neck (Abbreviated Injury Scale [AIS] mean difference -0.64 [-1.10 to -0.18]) and face (AIS mean difference -0.49 [-0.71 to -0.27]); and facial fracture (OR 0.26 [0.15-0.46]). CONCLUSION: Full-face motorcycle helmets are conditionally recommended to reduce traumatic brain injury, facial fractures, and injury severity.

Solitary Sign of Third Nerve Palsy in a Conscious Patient With Epidural Hemorrhage.

Epidural hematoma is a life-threatening complication of head injury, which often occurs as a result of blunt trauma to the skull. Unregulated hematoma expansion in any setting results in elevated intracranial pressure and may contribute to the compression of the oculomotor nerve among several other adversities culminating in various long-lasting complications in the future. In this case report, we present the findings of a rare, insightful case of a 47-year-old Southeast Asian male with no established prior medical history apart from being a victim of blunt trauma attributable to a fall four days before presenting to the emergency department with abrupt onset of diplopia and drooping of the left eyelid. The initial physical examination helped to establish a diagnosis of third nerve palsy. A non-contrast CT of the head was conducted, and its findings revealed the presence of a right temporal-parietal-occipital epidural hemorrhage, with no mass impact on the cerebral hemisphere. The patient later underwent a successful left temporoparietal craniotomy, during which 100-125 ml of blood was drained out. Post-surgery, a near-full reduction of ptosis was recorded at the end of the first week. This case report summarizes this ingenious depiction of a partial third nerve palsy presenting as the sole sign of the epidural hemorrhage in a cognizant patient.

Prevalence, trends and in-hospital outcomes of takotsubo syndrome among United States cannabis users.

BACKGROUND: Recent reports suggest a link between increased cannabis (marijuana) use and stress-cardiomyopathy (Takotsubo Syndrome, TTS) and related complications. Amidst recent trends in cannabis legalization and a paucity of data, it remains essential to evaluate the prevalence, trends and outcomes of TTS in cannabis users on a large-scale. METHOD: We studied prevalence and trends in TTS among adult cannabis users vs. non-users using the National Inpatient Sample (2007-2014). Baseline characteristics, comorbidities, and in-hospital outcomes of TTS were compared between cannabis users vs. non-users. Weighted logistic regression was performed adjusting for confounders to estimate the inpatient outcomes of TTS with vs. without cannabis use. RESULTS: The overall prevalence of TTS in cannabis users (47/100,000) was lower as compared to non-users (62/100,000). Rising trends in TTS among cannabis users (<11 to 82, ~8-fold) were more pronounced as compared to non-users (19 to 108, ~6 fold) per 100,000 hospitalizations from 2007 to 2014 (ptrend<0.001). Of all inpatient encounters for TTS (n=156,506), 1565 (0.1%) reported cannabis use. Polysubstance use including alcohol (4.1% vs. 24.4%), cocaine (0.4% vs. 8.5%), amphetamine (0.2% vs. 8.0%), and smoking (31.2% vs. 64.8%) was significantly higher in TTS-cannabis cohort. Although cardiovascular comorbidities were lower in TTS-cannabis cohort, the adjusted odds of all-cause mortality (aOR1.50, p<.05) were 50% higher in cannabis users compared to non-users without statistically significant difference in cardiac complications. CONCLUSIONS: Cannabis users showed lower prevalence but a more pronounced rising trend of TTS and subsequent risk of in-hospital mortality compared to non-users.

Rising Trends in Hospitalizations for Cardiovascular Events among Young Cannabis Users (18-39 Years) without Other Substance Abuse.

Background and objectives: Modern-day epidemiologic data on the risk and shifting landscape of occurrence of cardiovascular events in cannabis users remain inadequate and rather conflicting, especially amongst the young adult population. Furthermore, the problem of polysubstance use among youth is challenging for healthcare professionals and policy-makers. Previous studies report higher risk of concomitant use of tobacco, alcohol, cocaine, and amphetamine in young cannabis users. However, most of these studies did not eliminate the confounding effects of concomitant other substance abuse while assessing the incidence and outcome of cardiovascular events in cannabis users. Materials and methods: Using weighted discharge records from the National Inpatient Sample (NIS) from 2007-2014, we assessed the national trends in hospitalizations for major cardiovascular events including acute myocardial infarction (AMI), arrhythmia, stroke, and venous thromboembolic events (VTE) among young cannabis users (18-39 years), excluding cases with concomitant substance abuse with alcohol, tobacco, cocaine, and amphetamine. Results: Of 52.3 million hospitalizations without other substance abuse, 0.7 million (1.3%) young adults were current/former cannabis users. Among young adults without concomitant substance abuse, the frequency of admissions for AMI (0.23% vs. 0.14%), arrhythmia (4.02% vs. 2.84%), and stroke (0.33% vs. 0.26%) was higher in cannabis users as compared to non-users (p < 0.001). However, the frequency of admissions for VTE (0.53% vs. 0.84%) was lower among cannabis users as compared non-users. Between 2007 and 2014, we observed 50%, 79%, 300%, and 75% relative increases in hospitalizations for AMI, arrhythmias, stroke, and VTE, respectively, among young cannabis users as compared to non-users, showing relatively inferior or no ascent in the rates (ptrend < 0.001). Conclusions: The rising trends in hospitalizations for acute cardiovascular events among young cannabis users without concomitant other substance abuse call for future prospective well-designed studies to assess cannabis-related short-and long-term cardiovascular implications while simultaneously developing focused interventions towards raising awareness among the young population regarding the potential deleterious effects of cannabis use.

Significant but reasonable radiation exposure from computed tomography-related medical imaging in the ICU.

Admission to an intensive care unit (ICU) is associated with increased medical imaging and radiation exposure, yet few studies have estimated the risk of cancer associated with these examinations. The purpose of this study was to review computed tomography (CT) scans performed on patients admitted to two urban academic ICUs, predict their radiation exposure, and calculate their estimated lifetime attributable risk of cancer (LAR). An electronic chart review was performed on all CT scans performed between January 2007 and December 2011. The estimated effective dose of radiation was calculated for each CT, and the LAR for each patient was predicted. Mean radiation exposure was 22.2 ± 25.0 mSv with a mean LAR of 0.1 ± 0.2 % and a median of 0.6 % with a range of <0.001 to 3.4 %. Our cohort received radiation doses higher than recommended by guidelines; however, the critical nature of their admission may have warranted these imaging studies. Estimated risk of cancer in this population was overall low.

Autologous bone marrow mononuclear cell implantation therapy is an effective limb salvage strategy for patients with severe peripheral arterial disease.

OBJECTIVE: This study was conducted to determine if intramuscular and intra-arterial stem cell injections delay or prevent major limb amputations, improve ankle-brachial index measurements, relieve rest pain, and improve ulcer healing. METHODS: A prospective case series with interventions occurring between December 2007 and September 2012 and a 3-month minimum follow-up was conducted at an urban tertiary care referral hospital. Patients with severe limb-threatening peripheral arterial disease, without other options for revascularization, were eligible for enrollment. Dual intramuscular and intra-arterial injection of bone marrow mononuclear cells harvested from the iliac crest was performed. Major limb amputation at 3 months was the primary outcome measure. Secondary outcome measures included ankle-brachial index measurements, rest pain, and ulceration healing. Kaplan-Meier survivorship was performed to ascertain overall survivorship of the procedure. RESULTS: No complications related to the procedure were reported. Of 49 patients (56 limbs) enrolled, two patients (two limbs) died, but had not undergone major amputation, and five limbs (8.9%) underwent major amputation within the first 3 months. Three-month follow-up evaluations were conducted on the remaining 49 limbs (42 patients). Median postprocedure revised Rutherford and Fontaine classifications were significantly lower compared with median baseline classifications. After 3 months, seven patients (nine limbs) died but had not undergone major amputation, and seven limbs (14.3%) underwent major amputation. At a mean follow-up of 18.2 months, the remaining 33 limbs (29 patients) had not undergone a major amputation. Freedom from major adverse limb events (MALE) was 91.1% (95% confidence interval, 79.9-96.2) at 3 months and 75.6% (95% confidence interval, 59.4-86.1) at 12 months. CONCLUSIONS: This procedure was designed to improve limb perfusion in an effort to salvage limbs in patients for whom amputation was the only viable treatment option. The results of this analysis indicate that it is an effective strategy for limb salvage for patients with severe peripheral arterial disease.

Endovascular repair of concomitant vertebral artery and subclavian artery iatrogenic perforations.

Inadvertent arterial puncture is a well-established complication of central venous catheter insertion. The carotid artery is the most frequently injured artery involved with injury to the subclavian artery and vertebral artery being much less common. When these injuries do occur, they are often treated with open surgical repair or endovascular, with stent-graft placement or embolization. Repair of acute vertebral artery injury with endovascular stent-graft repair has not been well represented in the literature to date. The present report discusses the successful treatment of concomitant injuries to the left subclavian and left vertebral arteries from acute iatrogenic puncture with endovascular stent-graft placement.

A novel inhibitor of Mammalian triosephosphate isomerase found by an in silico approach.

Triosephosphate isomerase (TIM) is an essential, highly conserved component of glycolysis. Tumors are often dependent on glycolysis for energy and metabolite production (the Warburg effect). Glycolysis inhibitors thus show promise as cancer treatments. TIM inhibition, unlike inhibition of other glycolysis enzymes, also produces toxic methylglyoxal targeted to regions of high glycolysis, an effect that might also be therapeutically useful. Thus TIM is an attractive drug target. A total of 338,562 lead-like molecules were analyzed computationally to find TIM inhibitors by an efficient "double screen" approach. The first fragment-sized compounds were studied using structure-based virtual screening to identify binding motifs for mammalian TIM. Subsequently, larger compounds, filtered to meet the binding criteria developed in the first analysis, were ranked using a second round of structure-based virtual screening. A compound was found that inhibited mammalian TIM in vitro in the micromolar range. Docking and molecular dynamics (MD) suggested that the inhibitor made hydrogen bond contacts with TIM catalytic residues. In addition, hydrophobic contacts were made throughout the binding site. All predicted inhibitor-TIM interactions involved TIM residues that were highly conserved. The discovered compound may provide a scaffold for elaboration of other inhibitors.

Whole-body computed tomographic scanning leads to better survival as opposed to selective scanning in trauma patients: a systematic review and meta-analysis.

BACKGROUND: Traumatic injury in the United States is the Number 1 cause of mortality for patients 1 year to 44 years of age. Studies suggest that early identification of major injury leads to better outcomes for patients. Imaging, such as computed tomography (CT), is routinely used to help determine the presence of major underlying injuries. We review the literature to determine whether whole-body CT (WBCT), a protocol including a noncontrast scan of the brain and neck and a contrast-enhanced scan of the chest, abdomen, and pelvis, detects more clinically significant injuries as opposed to selective scanning as determined by mortality rates. METHODS: Scientific publications from 1980 to 2013 involving the study of the difference between pan scan and selective scan after trauma were identified. The Preferred Reporting Items for Systematic Reviews and Meta-analyses was used. Publications were categorized by level of evidence. Injury Severity Score (ISS) and pooled odds for mortality rate of patients who received WBCT scan versus those who received selective scans were compared. RESULTS: Of the 465 publications identified, 7 were included, composing of 25,782 trauma patients who received CT scan following trauma. Of the patients, 52% (n = 13,477) received pan scan and 48% (n = 12,305) received selective scanning. Overall ISS was significantly higher for patients receiving WBCT versus those receiving selective scan (29.7 vs. 26.4, p < 0.001, respectively). Overall mortality rate was significantly lower for WBCT versus selective scanning (16.9; 95% confidence interval [CI], 16.3-17.6 vs. 20.3; 95% CI, 19.6-21.1, p < 0.0002, respectively). Pooled odds ratio for mortality rate was 0.75 (95% CI, 0.7-0.79), favoring WBCT. CONCLUSION: Despite the WBCT group having significantly higher ISS at baseline compared with the group who received selective scanning, the WBCT group had a lower overall mortality rate and a more favorable pooled odds ratio for trauma patients. This suggests that in terms of overall mortality, WBCT scan is preferable to selective scanning in trauma patients. LEVEL OF EVIDENCE: Systematic review and meta-analysis, level III.

Mandatory health care insurance is associated with shorter hospital length of stay among critically injured trauma patients.

BACKGROUND: The implementation of the Affordable Care Act stimulated interest in outcomes of patients in Massachusetts, a state mandating health insurance as of 2006. We sought to determine the impact of an insurance mandate on hospital use and outcomes among trauma intensive care unit (ICU) patients. METHODS: This is a retrospective cohort study of trauma patients admitted to the ICU conducted at an academic, trauma center. Patients before (2004-2006) and after (2008-2012) the implementation of mandatory health insurance were compared using propensity matching to control for confounders. Outcomes were hospital length of stay (LOS), ICU LOS, in-hospital mortality, and discharge disposition. RESULTS: Overall, 1,668 trauma patients were included, with 530 matched on the propensity score in each group. Hospital LOS decreased by a median of 2.0 days, from 9.0 days (interquartile range, 4-15 days; p < 0.01) before to 7.0 days (interquartile range, 4-14) after implementation of the legislation. There were no differences in ICU LOS (3.0 days to 3.0 days, p = 0.44) and mortality (odds ratio [OR], 1.16; 95% confidence interval [CI], 0.83-1.63). Compared with discharges to home, the patients were more likely to be discharged home with home health services after the legislation (OR, 1.70; 95% CI, 1.08-2.68), but there was no significant change in the likelihoods of the patients being discharged to skilled nursing and rehabilitation facilities (OR, 0.97; 95% CI, 0.72-1.31). CONCLUSION: Implementation of health care reform was associated with a decrease in hospital LOS, with an increase in use of home health services and no change in ICU LOS and mortality among trauma ICU patients at our institution. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III.