[Recreational use of cannabis: From effects to harm. Epidemiological data]. / L'usage récréatif du cannabis : des effets aux méfaits. Données épidémiologiques.

As the medical use of so-called "therapeutic cannabis" is in the process of being approved in France, the opening to its recreational use is the next logical step, as it has been always the chronology followed in all countries. Indeed, those who have legalized the drug have previously approved its therapeutic use. This "justifying a project phase" stage seems unavoidable. Therefore, it is appropriate to recall the effects and misdeeds of the drug during its recreational use. The general population surveys carried out in France for 25 years by public health France and the French Observatory of Drugs and Drug Addiction, have followed the evolution of psychoactive substances consumption. Particular attention was focused on cannabis use, which, in a context of wide dissemination for a quarter of a century, rose steadily higher among younger generations, but also among older adults. France is the European country with the highest prevalence of cannabis use among young people and adults. Last 25 years, its diffusion has continued to expand, and the experimentation rate multiplied by near 4. Estimated at 12.7% in 1992, it reached 44.8% in 2017. Moreover, 25% of users in the year aged from 18 to 64 years old were at high risk of problematic use or dependence in 2017. This figure is worrying because it is constantly increasing; it affects 3% of 18-64-year-old, just over a million people.

Aluminum and vaccines: Current state of knowledge.

French people have never been so wary about vaccines. The use of aluminum salts in vaccine adjuvants to enhance effectiveness is one of the major reasons for this lack of confidence. The direct toxicity of aluminum is often put forward. Direct toxicity of aluminum has long been known-especially with occupational exposure-to be associated with characteristic clinical manifestations and increased blood aluminum level. Intoxication related to the excessive amount of an element in the body, whether be it lead poisoning following exposure to lead or mercury poisoning for instance, is always associated with metal increase in biological media. To date no link has been established between the direct toxicity of aluminum and vaccines. Aluminum levels in biological media of vaccinated subjects are not different from those of unvaccinated subjects. This is consistent with the very small amount of aluminum contained in one dose of vaccine. Indirect toxicity of aluminum was suggested to explain macrophagic myofasciitis in humans in 2011, a disease that could be mediated by an autoimmune/autoinflammatory mechanism. This hypothesis has recently been refuted in a large pharmaco-epidemiological study proving that aluminum-containing adjuvants of vaccines are not responsible for this autoimmune/autoinflammatory syndrome.

Silver absorption and toxicity evaluation of silver wound dressings in 40 patients with chronic wounds.

BACKGROUND: Silver-containing dressings are considered to be safe even though there have been some reports of complications, including argyria and various organ system dysfunctions. Despite the widespread use of silver dressings, little research has been done regarding the absorption and toxicity of silver. OBJECTIVE: We aimed to study the systemic absorption of silver in patients with chronic inflammatory wounds and to determine associated factors of systemic silver absorption and evaluated its association with silver toxicity. PATIENTS AND METHOD: Prospective, longitudinal, observational, multicentre, open-label pilot study. Patients from the Dermatology Departments of Lorraine (France) with the following inclusion criteria: (i) a chronic wound of more than 6 weeks and (ii) an ulcer needing silver-containing dressing were included. Before and after 28 days of treatment, clinical characteristics of the wound were recorded; hemogram, hepatic and renal functions, albumin sera and serum silver level were measured. RESULTS: Half of the cases displayed raised levels of silver after 1 month of treatment. Predictive factors for systemic silver absorption were wound area, anaemia and malnutrition with anaemia and malnutrition confirmed on multivariate analysis. Wound vascularization may also play a role, as a higher absorption was observed in cases of wound granulation without arterial components. No toxicity was detected. This work has also emphasized the slow elimination of silver from the body. CONCLUSION: Both long-term application and iterative treatments with silver dressings should be discouraged, especially in the elderly, who often suffer from malnutrition and anaemia to avoid potential cumulative toxicity.

Systemic sclerosis and exposure to heavy metals: A case control study of 100 patients and 300 controls.

OBJECTIVE: This case control study assessed: 1) the relationship of systemic sclerosis (SSc) related to exposure to heavy metals; and 2) the risk of SSc related to occupational exposure in male and female patients. METHODS: From 2005 to 2008, 100 patients with a definite diagnosis of SSc were included in the study; 3 age, gender, and smoking habit matched controls were selected for each patient. All SSc patients and controls underwent detection and quantification of heavy metal traces in hair samples, using multi-element inductively coupled plasma mass spectrometry (ICP-MS). RESULTS: SSc patients exhibited higher median levels of the following metals: antimony (p=0.001), cadmium (p=0.0003), lead (p=0.02), mercury (p=0.02), molybdenum (p=0.04), palladium (p<0.0001) and zinc (p=0.0003). A marked association between SSc and occupational exposure was further found for: 1) antimony (p=0.008) and platinum (p=0.04) in male patients; and 2) antimony (p=0.02), cadmium (p=0.001), lead (p=0.03), mercury (p=0.03), palladium (p=0.0003) and zinc (p=0.0001) in female patients CONCLUSION: The results show the impact of occupational risk factors in the development of SSc for: antimony, cadmium, lead, mercury, molybdenum, palladium and zinc. Thus, occupational exposure should be systematically checked in all SSc patients at diagnosis. Finally, the association between SSc and occupational exposure may be variable according to patients' gender.

[Pharmacokinetics, metabolism, and analytical methods of ethanol]. / Éthanol : pharmacocinétique, métabolisme et méthodes analytiques.

Alcohol is a licit substance whose significant consumption is responsible for a major public health problem. Every year, a large number of deaths are related to its consumption. It is also involved in various accidents, on the road, at work, as well as during acts of violence. Ethanol absorption and its fate are detailed. It is mainly absorbed in the small intestine. It accompanies the movements of the water, so it diffuses in all the tissues uniformly with the exception of bones and fat. The major route of ethanol detoxification is located into the liver. Detoxification is a saturable two-step oxidation. During the first stage ethanol is oxidized into acetaldehyde, under the action of alcohol dehydrogenase. During the second stage acetaldehyde is oxidized into acetate. Genetic factors or some drugs are able to disturb the absorption and the metabolism of ethanol. The analytical methods for the quantification of alcohol in man include analysis in exhaled air and in blood. The screening and quantification of ethanol for road safety are performed in exhaled air. In hospitals, blood ethanol determination is routinely performed by enzymatic method, but the rule for forensic samples is gas chromatography.

Importance of ERK activation in As2O3-induced differentiation and promyelocytic leukemia nuclear bodies formation in neuroblastoma cells.

Neuroblastoma malignant cell growth is dependent on their undifferentiated status. Arsenic trioxide (As2O3) induces neuroblastoma cell differentiation in vitro, but its mechanisms still remains unknown. We used three human neuroblastoma cell lines (SH-SY5Y, IGR-N-91, LAN-1) that differ from their MYCN and p53 status to explore the intracellular events activated by As2O3 and involved in neurite outgrowth, a morphological marker of differentiation. As2O3 (2µM) induced neurite outgrowth in all cell lines, which was dependent on ERK activation but independent on MYCN status. This process was induced either by a sustained (3 days) or a transient (2h) incubation with As2O3, indicating that very early events trigger the induction of differentiation. In parallel, As2O3 induced a rapid assembly of promyelocytic leukemia nuclear bodies (PML-NB) in an ERK-dependent manner. In conclusion, mechanisms leading to neuroblastoma cell differentiation in response to As2O3 appear to involve the ERK pathway activation and PML-NB formation, which are observed in response to other differentiating molecules such as retinoic acid derivates. This open new perspectives based on the use of treatment combinations to potentiate the differentiating effects of each drug alone and reduce their adverse side effects.

[Workplace testing of drugs of abuse and psychotropic drugs]. / Exploration biologique des drogues illicites et des médicaments psychotropes en milieu professionnel.

In France, workplace testing of drugs of abuse and psychotropic drugs is rarely performed; meanwhile it is a major public health problem. Furthermore, France is the European country that has been associated with the highest increase of the use of drugs of abuse, particularly cannabis. So workplace biological screening of drugs of abuse and of psychotropic drugs exposure is of major concern. New analytical techniques have been developed during the last years. The authors will consider analytical screening of drugs of abuse and particularly the comparison of analytical techniques applied to urine and saliva. The advantages and the disadvantages of these two matrices will be considered. Urinary and blood quantification will be reviewed, but also the interest of hair testing to explore chronic exposure. The research of psychotropic drugs in biological fluids is also a part of this paper. New analytical trends are promising and complete analysis of these substances will be soon routinely possible in blood using a single spot test.

On-line liquid chromatography/tandem mass spectrometry simultaneous determination of opiates, cocainics and amphetamines in dried blood spots.

A novel approach has been developed for the illicit drugs quantitative determination using dried blood spots (DBS) on filter paper. The illicit drugs tested were opiates (morphine and its 3- and 6-glucuronide metabolites, codeine, 6-monoacetylmorphine), cocainics (ecgonine methylester, benzoylecgonine, cocaine, cocaethylene) and amphetamines (amphetamine, methamphetamine, MDA, MDMA, MDEA). The described method, requiring a small blood volume, is based on high performance liquid chromatography coupled to tandem mass spectrometry using on-line extraction. A Whatman card 903 was spotted with 30µL of whole blood and left overnight to dry at room temperature. A 3-mm diameter disk was removed using a manual punch, suspended in 150µL of water for 10min with ultrasonication, and then 100µL was injected in the on-line LC-MS/MS system. An Oasis HLB was used as an extraction column and a C18 Atlantis as an analytical column. The chromatographic cycle was performed with 20mM ammonium formate buffer (pH 2.8) (solvent A) and acetonitrile/solvent A (90:10, v/v) gradient in 16min. Detection was performed in positive electrospray ionization mode (ESI+) with a Quattro Micro (Waters). Recoveries of all analytes were up to 80%. DBS were stored in duplicate at 4°C and -20°C for up to 6 months. Illicit drugs seemed to be much more stabled at -20°C. Furthermore, it was tested whether analysis of DBS may be as reliable as that of whole blood investigating authentic samples; significant correlations were obtained. This DBS assay has potential as rapid, sensitive and inexpensive option for the illicit drugs determination in small blood volumes, which seems of great interest in suspected cases of driving under the influence of drugs.

Accidental potassium dichromate poisoning. Toxicokinetics of chromium by ICP-MS-CRC in biological fluids and in hair.

Intoxications by chromium (Cr) compounds are very life threatening and often lethal. After oral ingestion of 2 or 3g of hexavalent Cr (Cr(VI)), gastrointestinal injury, but also hepatic and renal failure, often occurs which each leads to a fatal outcome in most patients. Cellular toxicity is associated with mitochondrial and lysosomal injury by biologically Cr(VI) reactive intermediates and reactive oxygen species. After Cr(VI) has been absorbed, there is not much that can be done except to control the main complications as the treatment is only symptomatic. The biotransformation of Cr(VI) to Cr(III) reduces the toxicity because the trivalent form does not cross cellular membranes as rapidly. In fact, more than 80% of Cr(VI) is cleared in urine as Cr(III). We report the case of a 58-year-old male patient who was admitted to hospital after accidental oral ingestion of a 30 g/L potassium dichromate (the estimated amount of ingested Cr is about 3g). ICP-MS equipped with a collision/reaction cell (CRC) and validated methods were used to monitor plasma (P), red blood cells (RBCs), urine (U) and hair chromium. For urine the results were expressed per gram of creatinine. After 7 days in the intensive care unit, the patient was discharged without renal or liver failure. P, RBC and U were monitored during 49 days. During this period Cr decreased respectively from 2088 µg/L to 5 µg/L, 631 µg/L to 129 µg/L and 3512 µg/g to 10 µg/g. The half-life was much shorter in P than in RBC as the poison was more quickly cleared from the P than from the RBC, suggesting a cellular trapping of the metal. Hair was collected 2 months after the intoxication. We report a very rare case of survival after accidental Cr poisoning which has an extremely poor prognosis and usually leads to rapid death. For the first time, this toxicokinetic study highlights a sequestration of chromium in the RBC and probably in all the cells.

Online liquid chromatography-tandem mass spectrometry cyanide determination in blood.

An original liquid chromatography-tandem mass spectrometry (LC-MS-MS) method coupled to online extraction has been developed for cyanide determination in blood. A method involving fluorimetric detection after naphthalene-2,3-dicarboxyaldehyde (NDA) complexation by taurine in the presence of cyanide was previously described. Its performance was limited because of the absence of an internal standard (IS). Using cyanide isotope (13)C(15)N as IS allowed quantification in MS-MS. After the addition of (13)C(15)N, 25 µL of blood were diluted in water and deproteinized with methanol. Following derivatization with NDA and taurine for 10 min at 4°C, 100 µL was injected into the online LC-MS-MS system. An Oasis HLB was used as an extraction column, and a C18 Atlantis was the analytical column. The chromatographic cycle was performed with an ammonium formate (20 mM, pH 2.8) (solvent A) and acetonitrile/solvent A (90:10, v/v) gradient in 6 min. Detection was performed in negative electrospray ionization mode (ESI(-)) with a Quattro Micro. For quantification, transitions of derivatives formed with CN and (13)C(15)N were monitored, respectively, as follows: 299.3/191.3 and 301.3/193.3. The procedure was fully validated, linear from 26 to 2600 ng/mL with limit of detection of 10 ng/mL. This method, using a small blood sample, is not only simple, but also time saving. The specificity and sensitivity of LC-MS-MS coupled to online extraction and using (13)C(15)N as the IS make this method very suitable for cyanide determination in blood and could be useful in forensic toxicology.

[A new medical concept: the metallic profile]. / Le profil métallique : un nouveau concept médical.

Over the past decade great progress has been made in metals and metalloids analysis. This analysis is a basic stage in toxicity assessment and is indispensable in achieving a realistic evaluation of substance toxicity. A recently introduced technique, inductively coupled plasma mass spectrometry (ICP-MS) is progressively replacing atomic absorption. This analysis permits multi-elementary determinations, approximately 30 elements, with an optimal gain in sensitivity in many biological matrices: i.e. whole blood, plasma, urine, hair, nail, biopsy samples. Moreover, this method allows semiquantitative determination with an additional 30 supplementary elements, which enables the toxicologist to sufficiently estimate the toxic levels and metal exposure. The authors demonstrate that the ICP-MS could be very useful for a wide range of clinical applications. Furthermore, this procedure offers new exploration possibilities in various fields such as clinical toxicology, forensic toxicology as well as work place testing or environmental exposure and permits epidemiologic studies. This analytical method in fact also provides a new scientific approach. To our knowledge we are the first to propose: the metallic profile.

MRI gadolinium-based contrast agents. Radiologists beware!

Gadolinium (Gd) is used in contrast agents as it enhances magnetic resonance imaging (MRI) signals. To reduce Gd toxicity, it is chelated into linear or macrocyclic complexes. Eight Gd-containing contrast agents have been approved by the European Medicines Agency (EMEA) for use in MRI, and six by the US Food and Drug Administration. Stability depends upon its physicochemical properties. When renal function is normal, the Gd is quickly cleared from the body by the kidneys. For patients with chronic kidney disease, the elimination is greatly reduced and Gd may be released from its chelate and deposit in body tissues, leading to nephrogenic systemic fibrosis (NSF). More than 200 cases of NSF have been reported in the world. NSF is characterized by an extensive fibrosis of skin and tissues, a very severe affection with possible lethal outcome. We propose recommendations to avoid the risk of NSF.

Application of inductively coupled plasma mass spectrometry multielement analysis in fingernail and toenail as a biomarker of metal exposure.

The application of inductively coupled plasma mass spectrometry (ICP-MS) to multielement analysis in fingernail and toenail as biological indices for metal exposure is presented. The ICP-MS measurements were performed using a Thermo Elemental X7CCT series. Fingernail specimens were obtained from 130 healthy volunteers, and paired fingernail and toenail samples from 50 additional healthy volunteers of both sexes were collected as well. After warm water and acetone decontamination, 20 mg fingernails and toenails were acid mineralized after a decontamination procedure, and 32-34 elements were simultaneously quantified after acid dilution following water calibration. Li, Be, B, Al, V, Cr, Mn, Co, Ni, Cu, Zn, Ga, Ge, As, Se, Rb, Sr, Mo, Pd, Ag, Cd, Sn, Sb, Te, Ba, La, Gd, W, Pt, Hg, Tl, Pb, Bi, and U could be validated in fingernail and toenail samples. Linearity was excellent, and the correlation coefficients were above 0.999. Quantification limits ranged from 0.04 pg/mg or ng/g (U) to 0.1 ng/mg or microg/g (B). Because of the lack of available certified nail reference material, an adequate quality assessment scheme was ensured by comparison with an interlaboratory nail-testing procedure, and the results showed optimal consistency for elements tested. Results are presented and compared with published multielement data. Six cases of domestic exposure to lead were diagnosed based on fingernail analysis. Application of ICP-MS multielement analysis in fingernail and toenail as a biomarker of metal and nonmetal exposure permits greater noninvasive control of industrial, domestic, or environmental exposure and is very useful for epidemiological studies.

[Illicit drugs, medications and traffic accidents]. / Drogues, médicaments et accidentologie.

The European Union (EU) has 25 member-states and 455 million inhabitants. Statistics on traffic accidents in the EU show that more than 45,000 people are killed annually, including 5200 in France. At the same time, nearly two million persons in the EU require medical treatment for traffic-accident-related injuries, including 109,000 in France. In addition, traffic accidents are the major cause of death of those individuals aged 15 to 24 years. One third of the EU inhabitants will be hospitalized during their life due to a traffic accident with a cost over 160 billion euro (2-3% of the Gross Domestic Product). An important contributing factor to crashes is the use of alcohol and/or illicit drugs or medication when driving, as they exert negative effects on cognition and psychomotor functions. For illicit drugs, abuse of cannabis with or without alcohol is a major concern for the EU. In fact, three million Europeans use cannabis daily and 80% of them drive after use. A number of French studies since 1999 have underlined the high prevalence of cannabis found in the blood of injured or killed drivers. From medical or judicial observations, it is clear that cannabis use increases the risk of traffic accidents. Many groups outside Europe have also shown the association between drug abuse and crashes. The number of casualties related to certain medicines, especially benzodiazepines remains at a high level, particularly in the elderly. In many countries the prevalence of medicinal drugs associated with car accidents is higher than with cannabis. Annex III of the European Union Council Directive of July the 29th 1991 in fact states that a driving license should not be issued to or renewed for applicants or drivers who are dependent on psychotropic substances or use them regularly. Recently, France has categorized the medicinal drugs available in the country by using three pictograms: level one yellow, "be careful"; level two orange, "be very careful"; level three red, "don't drive". It is an important campaign that increases awareness among the public and the medical professionals about the potential dangerous effects of medicinal drugs when driving. The EU objective of reducing the number of fatalities to 25,000 by 2010 will require strengthening measures against the use of alcohol, illicit and medicinal drugs by not well-informed drivers. It is not only a really great challenge, but also a significant investment towards improving public health in France as well as in Europe.

[Delta-9-tetrahydrocannabinol pharmacokinetics]. / Pharmacocinétique du delta-9-tétrahydrocannabinol (THC).

Delta-9-tetrahydrocannabinol (Delta-9-THC) is the main psychoactive ingredient of cannabis. Smoking is currently most common use of cannabis. The present review focuses on the pharmacokinetics of THC. The variability of THC in plant material which has significantly increased in recent years leads to variability in tissue THC levels from smoking, which is, in itself, a highly individual process. This variability of THC content has an important impact on drug pharmacokinetics and pharmacology. After smoking THC bioavailability averages 30%. With a 3.55% THC cigarette, a peak plasma level near 160 ng/mL occurs approximately 10 min after inhalation. THC is eliminated quickly from plasma in a multiphasic manner and is widely distributed to tissues, which is responsible for its pharmacologic effects. Body fat then serves as a long-term storage site. This particular pharmacokinetics explains the noncorrelation between THC blood level and clinical effects as is observed for ethanol. A major active 11-hydroxy metabolite is formed after both inhalation and oral dosing (20 and 100% of parent, respectively). The elimination of THC and its many metabolites, mainly THC-COOH, occurs via the feces and urine for several weeks. Thus, to confirm abstinence, urine THC-COOH analysis would be a useful tool. A positive result could be checked by gas chromatography-mass spectrometry THC blood analysis, indicative of a recent cannabis exposure.

Hair and fingernail gadolinium ICP-MS contents in an overdose case associated with nephrogenic systemic fibrosis.

Nephrogenic systemic fibrosis (NSF) is a rare acquired disorder affecting renal insufficiency patients. There is a growing recognition of the association between the rapid rise in the use of gadolinium (Gd)-containing contrast agents for magnetic resonance imaging (MRI), and the occurrence of acute nephrogenic systemic fibrosis. This case report concerns a 62-year-old woman with chronic renal insufficiency who underwent numerous MRI examinations using Gd-based contrast agents. For the first time, to our knowledge, Gd was performed in the NSF patient's blood, as well as in hair and in fingernails by inductively plasma coupled mass spectrometry. Gd contents in blood, hair and in fingernails were initially 300 to 1000 times higher compared to controls. These results are a new illustration of the strong association between the frequent use of Gd-based contrast media and NSF in patients with kidney diseases. Gd quantitative determination could be of major interest for patients with renal failure who are required to undergo repeated gadolinium-enhanced MRI examinations.