Impaired Driving Associated with the Synthetic Cannabinoid 5f-Adb.

Synthetic marijuana compounds are more potent than Δ9-tetrahydrocannabinol (∆9-THC) and are known to produce a wide variety of clinical symptoms including cardiac toxicity, seizures, and death. Erratic driving by a 45 y/o male was witnessed in the fall of 2017 and roadside evaluation of the driver by the responding law enforcement officer concluded that the driver was intoxicated. Comprehensive analysis of the cigarettes by gas chromatography-mass spectrometry detected the synthetic cannabinoid 5-fluoro-ADB (5F-ADB or 5F-MDMB-PINACA). Validated forensic liquid chromatography-tandem mass spectrometry (LC-MS/MS) methods were used to detect the 5-fluoro ADB metabolite 7 (26.37 ng/mL) in the driver's blood sample. No other drugs were detected. This case report is one of the first to conclusively show that designer synthetic cannabinoids, commonly referred to as "K2" and "Spice", can significantly impair driving at relatively low concentrations.

Metabolism of classical cannabinoids and the synthetic cannabinoid JWH-018.

Although the putative pharmacological targets of synthetic cannabinoids (SCBs) abused in "K2" and "Spice" are similar to Δ(9) -tetrahydrocannabinol (Δ(9) -THC), it remains unclear why SCB toxicity is similar yet different from marijuana. There are obvious potency and efficacy differences, but also important metabolic differences that help explain the unique adverse reactions associated with SCBs. This brief review discusses the limited research on the metabolism of the SCB JWH-018 and contrasts that with the metabolism of Δ(9) -THC.

A case of acute cerebral ischemia following inhalation of a synthetic cannabinoid.

OBJECTIVE: Synthetic cannabinoids are increasingly used in the United States as marijuana substitutes. However, reports of severe toxicity, resulting from their use, are limited. We present the case of acute cerebral infarction following synthetic cannabinoid inhalation. CASE REPORT: A 33-year-old man with no significant medical history presented at the emergency department with right-sided weakness and aphasia. He had smoked a synthetic cannabinoid (SC) product called "WTF" prior to the onset of symptoms. Physical examination showed right hemiparesis, dysarthria, and aphasia. Laboratory evaluation, electrocardiography, and computed tomography (CT) of the head were unremarkable. Following administration of intravenous tissue plasminogen activator, his symptoms improved. A repeat head CT showed acute infarction in the left insular cortex. His hypercoagulability panel was unremarkable, and the patient was discharged neurologically intact. Urine toxicology results were unremarkable. Analysis of the product by gas chromatography-mass spectrometry (GC-MS) procedure confirmed the presence of a synthetic cannabinoid known as XLR-11. CONCLUSION: XLR-11 has previously been associated with acute kidney injury in humans. However, there are no reports of it causing acute cerebral ischemic events. The close temporal association between XLR-11 inhalation and his stroke is concerning. Acute cerebral infarction may occur after XLR-11 use in healthy patients.

Severe toxicity following synthetic cannabinoid ingestion.

OBJECTIVE: To report a case of seizures and supraventricular tachycardia (SVT) following confirmed synthetic cannabinoid ingestion. BACKGROUND: Despite widespread use of legal synthetic cannabinoids, reports of serious toxicity following confirmed use of synthetic cannabinoids are rare. We report severe toxicity including seizures following intentional ingestion of the synthetic cannabinoid JWH-018 and detail confirmation by laboratory analysis. CASE REPORT: A healthy 48 year old man had a generalized seizure within thirty minutes of ingesting an ethanol mixture containing a white powder he purchased from the Internet in an attempt to get high. Seizures recurred and abated with lorazepam. Initial vital signs were: pulse, 106/min; BP, 140/88 mmHg; respirations, 22/min; temperature, 37.7 °C. A noncontrast computed tomography of the brain and EEG were negative, and serum chemistry values were normal. The blood ethanol concentration was 3.8 mg/dL and the CPK 2,649 U/L. Urine drug screening by EMIT was negative for common drugs of abuse, including tetrahydrocannabinol. On hospital day 1, he developed medically refractory SVT. The patient had no further complications and was discharged in his normal state of health 10 days after admission. The original powder was confirmed by gas chromatography mass spectrometry to be JWH-018, and a primary JWH-018 metabolite was detected in the patient's urine (200 nM) using liquid chromatography tandem mass spectrometry. DISCUSSION: Synthetic cannabinoids are legal in many parts of the world and easily obtained over the Internet. Data on human toxicity are limited and real-time confirmatory testing is unavailable to clinicians. The potential for toxicity exists for users mistakenly associating the dose and side effect profiles of synthetic cannabinoids to those of marijuana. CONCLUSION: Ingestion of JWH-018 can produce seizures and tachyarrhythmias. Clinicians, lawmakers, and the general public need to be aware of the potential for toxicity associated with synthetic cannabinoid use.

Linoleic acid prevents chloride influx and cellular lysis in rabbit renal proximal tubules exposed to mitochondrial toxicants.

Despite many studies elucidating the mechanisms of necrotic cell death, the role of fatty acids released during necrosis remains to be determined. The goals of this study were to determine whether linoleic acid could protect rabbit renal proximal tubules (RPT) from necrotic cell death associated with mitochondrial dysfunction and oxidative injury and to determine the mechanisms involved. Exposure to antimycin A (10 microM) for 1 h or hypoxia (perfusion with 95% N(2)/5% CO(2)) for 1 or 2 h induced approximately 70% cellular lysis, as measured by lactate dehyrogenase release, versus 10% in controls. Preincubation with linoleic acid (100 microM) fully protected RPT from cellular lysis. RPT were also protected from lysis if linoleic acid was added 15 min after the addition of antimycin A. Measurements of free intracellular Ca(2+) concentrations showed that linoleic acid did not prevent the rise in intracellular Ca(2+) associated with a 30-min exposure to antimycin A. However, the influx of extracellular (36)Cl(-) following a 30-min exposure to antimycin A was ameliorated in the presence of linoleic acid. Linoleic acid did not prevent cellular lysis after exposure to hypoxia/reoxygenation (1 h/1 h) or t-butyl hydroperoxide (500 microM, 3 h). These data suggest that linoleic acid protects RPT during the late phase of cell death associated with inhibition of the electron transport chain but not oxidative injury. Several other fatty acids also protected RPT from lysis, and structure-activity relationship studies suggest that a free carboxyl terminus and at least one double bond are required for this action.

Analysis of the toxic effects of linoleic acid, 12,13-cis-epoxyoctadecenoic acid, and 12,13-dihydroxyoctadecenoic acid in rabbit renal cortical mitochondria.

P450 epoxidation of linoleic acid has been associated with many pathological conditions that often lead to acute renal failure. However, there is only suggestive evidence that linoleic acid monoepoxides and/or linoleic diols directly induce mitochondrial dysfunction. Using isolated rabbit renal cortical mitochondria (RCM), we found that linoleic acid (50 microM) and the linoleic acid monoepoxide, cis-12,13-epoxy-9-octadecenoic acid (12,13-EOA, 50 microM) increased state 4 and oligomycin-insensitive respiration and reduced state 3 and oligomycin-sensitive respiration. Concomitant with these effects, linoleic acid and 12,13-EOA decreased mitochondrial membrane potential (DeltaPsi). In contrast, the hydrolyzed product of 12,13-EOA, 12,13-dihydroxyoctadecenoic acid (12,13-DHOA, 50 microM), had no effect on state 3, state 4, oligomycin-sensitive, and oligomycin-insensitive respiration, and DeltaPsi. Neither linoleic acid or its metabolites altered uncoupled respiration, which suggests that these compounds have no affect on electron transport chain in RCM. Nucleotides such as ATP (0.5 mM) and GDP (0.5 mM) partially prevented the decrease in DeltaPsi but did not attenuate the increase in oligomycin-insensitive respiration after exposure to linoleic acid (50 microM) and 12,13-EOA (50 microM). These results demonstrate that linoleic acid metabolism to the 12,13-DHOA is a detoxification pathway that prevents mitochondrial dysfunction in RCM. The increase in state 4 respiration concomitant with decreases in state 3 respiration and DeltaPsi suggest that, in addition to uncoupling effects, linoleic acid and 12,13-EOA may have other effects, such as alterations of mitochondrial membranes. The inability of ATP and GDP to fully attenuate the uncoupling effects of linoleic acid and 12,13-EOA suggests that these effects are mediated through a nucleotide-independent mechanism.

Defining mechanisms of toxicity for linoleic acid monoepoxides and diols in Sf-21 cells.

Linoleic acid monoepoxides have been correlated with many pathological conditions. Studies using insect cells derived from Spodoptera frugiperda (Sf-21 cells) have suggested that conversion of the epoxides to the diols is required for toxicity. However, more recent studies using rabbit renal proximal tubules have suggested that linoleic acid monoepoxides are direct mitochondrial toxins. To better understand these discrepancies, we compared the toxicity of these linoleic acid metabolites in Sf-21 cells using mitochondrial respiration as an end point. Linoleic acid (100 microM) and 12,13-epoxy-9-octadecenoic acid (12,13-EOA, 100 microM) increased the rate of oligomycin-insensitive respiration by approximately 3.5- and 3-fold, respectively, decreased the rate of oligomycin-sensitive respiration by approximately 52 and 68%, respectively, and had no effect on the integrity of the electron transport chain. These effects were concentration-dependent, occurred within 1 min, and recovered to basal levels within 45 min. 12,13-Dihydroxy-9-octadecenoic acid (12,13-DHOA, 100 microM) had no effect on oligomycin-insensitive respiration but decreased the rate of oligomycin-sensitive respiration and uncoupled respiration in a concentration-dependent manner. Approximately 79 and 68% of oligomycin-sensitive respiration and uncoupled respiration was inhibited by 12,13-DHOA (100 microM), respectively. These effects occurred within 1 min and were not reversible in 6 h. Effects similar to those induced by 12,13-DHOA (100 microM) were observed using 12,13-EOA (100 microM) in Sf-21 cells expressing human soluble epoxide hydrolase. These data suggest that in this Sf-21 model linoleic acid and linoleic monoepoxides have transient uncoupling effects, whereas the primary mechanism of toxicity for linoleic acid diols in this model is inhibition of the electron transport chain.

Analysis of the cytotoxic properties of linoleic acid metabolites produced by renal and hepatic P450s.

Cytochrome P450 epoxidation of linoleic acid produces biologically active metabolites which have been associated with many pathological conditions that often lead to acute renal failure. In the present study, we evaluated the ability of specific cytochrome P450s to produce linoleic acid monoepoxides. We then tested the cytotoxic properties of linoleic acid, linoleic acid monoepoxides, and corresponding diols in a rabbit renal proximal tubule model. CYP1A2, CYP2E1, CYP2J2, CYP2J3, CYP2J5, and CYP2J9 metabolized linoleic acid at rates comparable to arachidonic acid and produced linoleic acid monoepoxides as major products. Cytotoxicity studies showed that linoleic acid, linoleic acid monoepoxides, and corresponding diols are toxic at pathologically relevant concentrations (100-500 microM). Concentration-dependent studies showed that linoleic acid and linoleic acid monoepoxides are the most toxic and induce mitochondrial dysfunction prior to cell death. Cytoprotectants known to block cell death associated with mitochondrial dysfunction and oxidative stress did not prevent cell death induced by linoleic acid and linoleic acid monoepoxides. This study shows that P450s in the CYP1 and CYP2 gene families metabolize linoleic acid to linoleic acid monoepoxides and that the monoepoxides, as well as linoleic acid, disrupt mitochondrial function without causing oxidative stress.

Cytotoxicity of linoleic acid diols to renal proximal tubular cells.

Monoepoxides of linoleic acid (leukotoxin and isoleukotoxin) have been associated with a variety of pathophysiological diseases in humans including multiple organ failure. They also have been shown to be toxic when injected into experimental animals. Because leukotoxin and isoleukotoxin are excellent substrates for epoxide hydrolases, we tested the hypothesis that the diol metabolites are less toxic than the parent monoepoxides using the rabbit renal proximal tubule (RPT) suspension model. An equimolar mixture of the positional isomers of the methyl esters of leukotoxin and isoleukotoxin did not cause cell death to RPT cells at concentrations up to 1 mm using lactate dehydrogenase release as the endpoint. The corresponding diols, however, caused cell death in a time- and concentration-dependent manner beginning at 4 hr and reaching 42% cell death in 6 hr at 1 mm. Cell death was not due to oxidative stress since malondialdehyde content did not increase and the iron chelator deferoxamine and the antioxidant N,N'-diphenyl-1, 4-phenylenediamine were not cytoprotective. In contrast, cell death was associated with mitochondrial dysfunction with respiration decreasing 54% prior to the onset of cell death. Secondary to the mitochondrial dysfunction, the diols completely inhibited active Na+ transport within 30 min of addition. These results suggest that the in vivo toxicity and pathophysiology previously attributed to the monoepoxides of linoleic acid may be due to the diol metabolites.

Diverse cytoprotectants prevent cell lysis and promote recovery of respiration and ion transport.

Numerous agents have been reported to prevent cell lysis. However, little information is available concerning the ability of cytoprotectants to promote the return of physiological functions. The goal of this study was to determine whether a diverse group of cytoprotectants prevent cell lysis and promote the recovery of respiration and ion transport following anoxia (60 min)/reoxygenation (60 min) in rabbit renal proximal tubule (RPT) suspensions. Cell lysis (LDH release) was determined immediately following the anoxic and reoxygenation periods. Mitochondrial function (basal respiration) and active Na+ transport (ouabain-sensitive respiration) was determined after the reoxygenation period. LDH release increased to 75 +/- 11% after the anoxic period and did not increase further during the reoxygenation period. LDH release in controls was 6 +/- 1% and did not vary over time. Glycine (2 mM), strychnine (1 mM), nifedipine (100 microM) and niflumic acid (100 microM) added immediately prior to the anoxic period completely blocked LDH release. All cytoprotectants increased basal respiration from 39 +/- 7% of controls in the anoxic samples to 65-77% of controls. Glycine, strychnine and nifedipine increased ouabain-sensitive respiration from 10 +/- 3% of controls in anoxic samples to 51-77% of control. Niflumic acid did not increase ouabain-sensitive respiration. These results demonstrate that glycine, strychnine and nifedipine are "true' cytoprotectants preventing both cell lysis and promoting the recovery of mitochondrial function and ion transport after an anoxic insult.

A rapid beta-NADH-linked fluorescence assay for lactate dehydrogenase in cellular death.

Lactate dehydrogenase (LDH) release in a common marker of cellular death. Traditionally, the fraction of LDH released has been measured using a NADH-linked UV-Vis spectrophotometric method. The limitation of this method is that samples are usually run serially and thus is time intensive. Therefore, we developed a NADH-linked LDH assay using a fluorescence plate reader that had a correlation of 0.95 with the traditional UV-Vis spectrophotometric method. Using rabbit renal proximal tubule suspensions at a concentration of 1 mg cellular protein/ml of media, the fluorescence assay can determine LDH release in 22 samples in 2 min using 12 microL of cellular homogenates and 150 microL of media. The parallel processing of samples and smaller volumes used in the fluorescence assay results in decreased analysis time and costs.

Is serodiagnosis of herpes simplex encephalitis safe?

We present a case of probable tuberculous meningitis in which serological changes 'diagnostic' of herpes simplex encephalitis were found. Evidence is provided that the serological changes in this case represent a true false positive, and that reliance on clinical plus serological criteria to diagnose herpes simplex encephalitis could result in failure to diagnose and treat tuberculous meningitis.

The efficacy of medical stabilization prior to myocardial revascularization in early refractory postinfarction angina.

The timing of coronary artery bypass graft (CABG) surgery in patients with persistent, severe myocardial ischemia after an acute myocardial infarction is controversial. Based on the previous disappointing clinical experience with urgent surgery, a period of medical stabilization (mean ten days, range two to 28) prior to surgery was employed in a prospective nonrandomized clinical trial. The frequent use of intravenous nitroglycerin and intra-aortic balloon pumping was important in allowing preoperative clinical stabilization in these patients who were refractory to conventional medical therapy. The combined medical-surgical treatment protocol was associated with no early or late mortality in 20 patients who suffered preoperative myocardial infarction and demonstrated refractory post-infarction angina. Although these patients were considered to be high-risk surgical candidates, the incidence of perioperative myocardial damage in this selected group was comparable with that observed in patients undergoing elective CABG surgery at this institution without recent preoperative myocardial infarction. In order to determine the hemodynamic effectiveness of this selected patient management process, perioperative changes in left ventricular performance were determined by multigated cardiac blood pool imaging. Computer-based analysis of this radionuclide-related data allowed the accurate determination of ejection fraction (EF). Those patients with preoperative subendocardial infarction (N = 12) had no decrease in global EF 24 hours after operation and significant increases in EF seven days and eight months after operation. This pattern is analogous to that observed in patients without preoperative myocardial necrosis undergoing elective CABG surgery at this institution. Those patients with recent preoperative transmural myocardial infarction (N = 8) showed a decrease in EF 24 hours after operation, but recovered to preoperative levels seven days and eight months after operation. There was, however, no increase in EF in this subgroup of patients. On the basis of this study, the authors tentatively recommend a concerted effort at preoperative medical stabilization prior to CABG surgery in patients with persistent refractory myocardial ischemia soon after acute myocardial necrosis. A prospective, randomized study comparing urgent and delayed surgery, as well as nonsurgical treatment, will be necessary to define more precisely optimal management of this subgroup of cardiac patients.

Statistical analysis of an urban population of 236 patients with head and neck pain. Part II. Patient symptomatology.

A large group of patients (236) was examined for Myofascial Pain Dysfunction Syndrome. The symptoms of the patients were recorded, using as a guide the classic parameters of pain and tenderness to the head and neck muscles and temporomandibular joint, joint sounds, and limited function. Our basic data were similar to those of other studies. The significant difference of this study is the detail with which the symptoms were studied. The relationships of suspected etiology and symptoms were compared and discussed. This paper is the second of a three part series. The first part dealt with the demographic profile of our patient population. The third part will present the data dealing with treatment modalities and relief.

Statistical analysis of an urban population of 236 patients with head and neck pain. Part I. Patient profile.

A large group of patients (236) was examined for myofascial pain dysfunction syndrome. The parameters used for diagnosis of the syndrome were pain and tenderness in the head and neck muscles and temporomandibular joint, joint sounds, and limited function. It was found that the demographic profile of our patient population did not vary greatly from those reported previously in other studies. However, we did examine more details of the patients' backgrounds than any other single study. The relationships of age, sex, occupation, marital status, emotional stress, and head trauma were discussed.

Statistical analysis of an urban population of 236 patients with head and neck pain. Part III. Treatment modalities.

Data collected from standardized temporomandibular joint examination forms and treatment records of patients diagnosed as having Myofascial Pain Dysfunction Syndrome and treated using occlusal adjustment as the primary mode have been presented. A higher success rate was found in those patients: (1) with a chief complaint of pain confined to the area of one or both temporomandibular joints only, (2) whose answer to location of pain on initial examination was identified as confined solely to the region of one or both temporomandibular joints, (3) with muscle tenderness to palpation to one or both lateral pterygoid muscles with no other muscle involvement, (4) recorded as having a centric discrepancy in the absence of a balancing side prematurity, and (5) in the 31 to 40-year-old age group.