Cannabis in Combat Sports: position statement of the association of ringside physicians.

and ARP Position StatementBased on the available body of scientific evidence and with the goals of promoting safety of combat sports athletes and striving for the advancement of clean sport, the Association of Ringside Physicians recommends the following regarding cannabis:●Use of marijuana or synthetic cannabinoids by combat sports athletes is discouraged due to unproven benefits and many known adverse effects. Acute use can impair cognition and complex motor function, which likely leads to reduced performance in combat sports. Chronic use can increase risk for heart and lung disease, several cancers, schizophrenia, and can reduce testosterone in men and impair fertility. Benefits from cannabis in most contexts, including athletic performance, have not been proven.●Use of topical purified CBD is neither encouraged nor discouraged.●Since acute cannabis intoxication can impair complex cognitive and motor function, any athlete suspected of acute intoxication at the time of competition - based on clinical judgment - should be banned from that competition.●Wide-scale regulation of cannabis based on quantitative testing has limited usefulness in combat sports, for the following reasons:○Cannabis is not ergogenic and is likely ergolytic.○Concentrations in body fluids correlate poorly with clinical effects and timing of use.○Access to testing resources varies widely across sporting organizations.

Identification and management of marine envenomations in pediatric patients

Marine envenomations can cause a diverse array of clinical syndromes. Systemic and life-threatening reactions, as well as delayed presentations, can occur. The pediatric population is at higher risk for serious reactions to envenomations because their greater body surface area and smaller body mass can lead to a higher relative venom load. Although the majority of the literature on marine envenomations is of low quality, the available literature does suggest that management varies depending on the geographic location. This issue reviews both common and life-threatening presentations of marine envenomations, highlights key aspects of the history and physical examination that will help narrow the differential, and offers recommendations for management based on the envenomating creature and geographic location.

The Virtual Toxicology Journal Club: the Dissemination and Discussion of Noteworthy Manuscripts Using Twitter.

BACKGROUND: Twitter-based chat groups (tweetchats) structured as virtual journal clubs have been demonstrated to provide value to learners. In order to promote topics in medical toxicology, we developed the #firesidetox tweetchat as a virtual journal club to discuss and disseminate topics in medical toxicology. METHODS: A group of medical toxicologists from the American College of Medical Toxicology (ACMT) Public Affairs Committee and editorial board of the Journal of Medical Toxicology (JMT) developed a quarterly one hour tweetchat featuring JMT manuscripts. We gathered basic twittergraphics and used a healthcare hashtag aggregator to measure the number of impressions, participants, and tweets per tweetchat session. A qualitative analysis of important themes from #firesidetox was also completed. RESULTS: During five tweetchats over 12 months, we attracted a mean of 23 participants generating a mean of 150 tweets per #firesidetox tweetchat. Tweets generated a mean of 329,200 impressions (unique user views): these impressions grew by 300% from the first through fifth #firesidetox. The majority of participants self-identified as medical toxicologists or physician learners. Although most were from the USA, participants also came from Australia, Poland, and Qatar. Most tweets centered on medical education and 7.9% tweets were learner-driven or questions asking for a medical toxicologist expert opinion. CONCLUSION: The #firesidetox attracted a diverse group of toxicologists, learners, and members of the public in a virtual journal club setting. The increasing number of impressions, participants, and tweets during #firesidetox demonstrates the tweetchat model to discuss pertinent toxicology topics is feasible and well received among its participants.

Cannabinoid Hyperemesis Syndrome: Public Health Implications and a Novel Model Treatment Guideline.

INTRODUCTION: Cannabinoid hyperemesis syndrome (CHS) is an entity associated with cannabinoid overuse. CHS typically presents with cyclical vomiting, diffuse abdominal pain, and relief with hot showers. Patients often present to the emergency department (ED) repeatedly and undergo extensive evaluations including laboratory examination, advanced imaging, and in some cases unnecessary procedures. They are exposed to an array of pharmacologic interventions including opioids that not only lack evidence, but may also be harmful. This paper presents a novel treatment guideline that highlights the identification and diagnosis of CHS and summarizes treatment strategies aimed at resolution of symptoms, avoidance of unnecessary opioids, and ensuring patient safety. METHODS: The San Diego Emergency Medicine Oversight Commission in collaboration with the County of San Diego Health and Human Services Agency and San Diego Kaiser Permanente Division of Medical Toxicology created an expert consensus panel to establish a guideline to unite the ED community in the treatment of CHS. RESULTS: Per the consensus guideline, treatment should focus on symptom relief and education on the need for cannabis cessation. Capsaicin is a readily available topical preparation that is reasonable to use as first-line treatment. Antipsychotics including haloperidol and olanzapine have been reported to provide complete symptom relief in limited case studies. Conventional antiemetics including antihistamines, serotonin antagonists, dopamine antagonists and benzodiazepines may have limited effectiveness. Emergency physicians should avoid opioids if the diagnosis of CHS is certain and educate patients that cannabis cessation is the only intervention that will provide complete symptom relief. CONCLUSION: An expert consensus treatment guideline is provided to assist with diagnosis and appropriate treatment of CHS. Clinicians and public health officials should identity and treat CHS patients with strategies that decrease exposure to opioids, minimize use of healthcare resources, and maximize patient safety.

Assessing the Effect of a Medical Toxicologist in the Care of Rattlesnake-envenomated Patients.

BACKGROUND: Rattlesnake envenomation is an important problem in the United States, and the management of these envenomations can be complex. Despite these complexities, however, the majority of such cases are managed without the involvement of a medical toxicologist. The primary objective of this study was to evaluate the impact of a medical toxicology service (MTS) on the length of stay (LOS) of such patients. METHODS: The authors conducted a retrospective study at six centers in California. Patients were included if they were admitted in the 2 years before the establishment of a MTS (pre-MTS) or in the 2 years after the creation of a MTS (post-MTS). RESULTS: A total of 300 subjects were included (169 pre-MTS, 131 post MTS). Baseline characteristics between the pre-MTS and post-MTS groups were very similar. The creation of a MTS was associated with a significant reduction in the mean (95% confidence interval) LOS (69.5 [59.1-79.9] hours vs. 48.1 [41.4-54.8] hours). This reduced LOS was not associated with any statistically significant change in readmission rates. CONCLUSION: Rattlesnake bite patients treated by a medical toxicologist have a significantly reduced LOS compared to those without direct involvement of a medical toxicologist.

Cannabinoid hyperemesis syndrome: potential mechanisms for the benefit of capsaicin and hot water hydrotherapy in treatment.

INTRODUCTION: Cannabinoid hyperemesis syndrome is a clinical disorder that has become more prevalent with increasing use of cannabis and synthetic cannabinoids, and which is difficult to treat. Standard antiemetics commonly fail to alleviate the severe nausea and vomiting characteristic of the syndrome. Curiously, cannabinoid hyperemesis syndrome patients often report dramatic relief of symptoms with hot showers and baths, and topical capsaicin. OBJECTIVES: In this review, we detail the pharmacokinetics and pharmacodynamics of capsaicin and explore possible mechanisms for its beneficial effect, including activation of transient receptor potential vanilloid 1 and neurohumoral regulation. Putative mechanisms responsible for the benefit of hot water hydrotherapy are also investigated. METHODS: An extensive search of PubMed, OpenGrey, and Google Scholar from inception to April 2017 was performed to identify known and theoretical thermoregulatory mechanisms associated with the endocannabinoid system. The searches resulted in 2417 articles. These articles were screened for relevant mechanisms behind capsaicin and heat activation having potential antiemetic effects. References from the selected articles were also hand-searched. A total of 137 articles were considered relevant and included. Capsaicin: Topical capsaicin is primarily used for treatment of neuropathic pain, but it has also been used successfully in some 20 cases of cannabinoid hyperemesis syndrome. The pharmacokinetics and pharmacodynamics of capsaicin as a transient receptor potential vanilloid 1 agonist may explain this effect. Topical capsaicin has a longer half-life than oral administration, thus its potential duration of benefit is longer. Capsaicin and transient receptor potential vanilloid 1: Topical capsaicin binds and activates the transient receptor potential vanilloid 1 receptor, triggering influx of calcium and sodium, as well as release of inflammatory neuropeptides leading to transient burning, stinging, and itching. This elicits a novel type of desensitization analgesia. Transient receptor potential vanilloid 1 receptors also respond to noxious stimuli, such as heat (>43 °C), acids (pH <6), pain, change in osmolarity, and endovanilloids. The action of topical capsaicin may mimic the effect of heat-activation of transient receptor potential vanilloid 1. Endocannabinoid system and transient receptor potential vanilloid 1: Cannabinoid hyperemesis syndrome may result from a derangement in the endocannabinoid system secondary to chronic exogenous stimulation. The relief of cannabinoid hyperemesis syndrome symptoms from heat and use of transient receptor potential vanilloid 1 agonists suggests a complex interrelation between the endocannabinoid system and transient receptor potential vanilloid 1. Temperature regulation: Hot water hydrotherapy is a mainstay of self-treatment for cannabinoid hyperemesis syndrome patients. This may be explained by heat-induced transient receptor potential vanilloid 1 activation. "Sensocrine" antiemetic effects: Transient receptor potential vanilloid 1 activation by heat or capsaicin results in modulation of tachykinins, somatostatin, pituitary adenylate-cyclase activating polypeptide, and calcitonin gene-related peptide as well as histaminergic, cholinergic, and serotonergic transmission. These downstream effects represent further possible explanations for transient receptor potential vanilloid 1-associated antiemesis. CONCLUSIONS: These complex interactions between the endocannabinoid systems and transient receptor potential vanilloid 1, in the setting of cannabinoid receptor desensitization, may yield important clues into the pathophysiology and treatment of cannabinoid hyperemesis syndrome. This knowledge can provide clinicians caring for these patients with additional treatment options that may reduce length of stay, avoid unnecessary imaging and laboratory testing, and decrease the use of potentially harmful medications such as opioids.

Electronic pharmacopoeia: a missed opportunity for safe opioid prescribing information?

Errors in prescribing of dangerous medications, such as extended release or long acting (ER/LA) opioid forlmulations, remain an important cause of patient harm. Prescribing errors often relate to the failure to note warnings regarding contraindications and drug interactions. Many prescribers utilize electronic pharmacopoeia (EP) to improve medication ordering. The purpose of this study is to assess the ability of commonly used apps to provide accurate safety information about the boxed warning for ER/LA opioids. We evaluated a convenience sample of six popular EP apps available for the iPhone and an online reference for the presence of relevant safety warnings. We accessed the dosing information for each of six ER/LA medications and assessed for the presence of an easily identifiable indication that a boxed warning was present, even if the warning itself was not provided. The prominence of precautionary drug information presented to the user was assessed for each app. Provided information was classified based on the presence of the warning in the ordering pathway, located separately but within the prescribers view, or available in a separate screen of the drug information but non-highlighted. Each program provided a consistent level of warning information for each of the six ER/LA medications. Only 2/7 programs placed a warning in line with dosing information (level 1); 3/7 programs offered level 2 warning and 1/7 offered level 3 warning. One program made no mention of a boxed warning. Most EP apps isolate important safety warnings, and this represents a missed opportunity to improve prescribing practices.

Spice drugs are more than harmless herbal blends: a review of the pharmacology and toxicology of synthetic cannabinoids.

"K2" and "Spice" drugs (collectively hereafter referred to as Spice) represent a relatively new class of designer drugs that have recently emerged as popular alternatives to marijuana, otherwise characterized as "legal highs". These drugs are readily available on the Internet and sold in many head shops and convenience stores under the disguise of innocuous products like herbal blends, incense, or air fresheners. Although package labels indicate "not for human consumption", the number of intoxicated people presenting to emergency departments is dramatically increasing. The lack of validated and standardized human testing procedures and an endless supply of potential drugs of abuse are primary reasons why researchers find it difficult to fully characterize clinical consequences associated with Spice. While the exact chemical composition and toxicology of Spice remains to be determined, there is mounting evidence identifying several synthetic cannabinoids as causative agents responsible for psychoactive and adverse physical effects. This review provides updates of the legal status of common synthetic cannabinoids detected in Spice and analytical procedures used to test Spice products and human specimens collected under a variety of clinical circumstances. The pharmacological and toxicological consequences of synthetic cannabinoid abuse are also reviewed to provide a future perspective on potential short- and long-term implications.

Rates of positive blood, urine, and cerebrospinal fluid cultures in children younger than 60 days during the vaccination era.

BACKGROUND: Fever is a common reason children present to the emergency department. The goal of this study was to determine the rates and the etiology of bacterial infection in children younger than 2 months during the vaccination era. METHODS: This is a retrospective chart review performed at a tertiary care hospital. Electronic medical records were used to identify patients who had a workup for fever/sepsis in the emergency department. The search was limited to identifying only children younger than 60 days. RESULTS: A total of 207 patients satisfied the inclusion/exclusion criteria. In children younger than 28 days, the blood culture-positive rate was 2.7% (range, 0.0%-6.4%), the urine culture-positive rate was 10.7% (range, 3.5%-17.8%), and the cerebrospinal fluid-positive rate (excluding enteroviral infections) was 0% (range, 0.0%-3.9%). In children 29 to 60 days, the blood culture-positive rate was 1.5% (range, 0.0%-3.6%), urine culture-positive rate was 8.5% (range, 3.7%-13.3%), and the cerebrospinal fluid-positive rate (excluding enteroviral infections) was 1.7% (range, 0.0%-5.0%). Urinary tract infections due to Escherichia coli were very common, whereas no cases of Haemophilus influenzae and one case of Streptococcus pneumoniae were detected. CONCLUSIONS: Urinary tract infections due to E. coli are very common in this age group. The classic pathogens H. influenzae and S. pneumoniae were essentially nonexistent in this study possibly because of herd immunity obtained through current vaccination practices.

Auricular squamous cell carcinoma.

Squamous cell carcinoma is a common cancer to the head and neck region that is typically diagnosed when it is 2 cm in size. This case report illustrates a patient who had neglected an auricular carcinoma for over a year. At the time of presentation the entire ear was infected with pseudomonas and yeast and chronic friability and bleeding caused an anemia which required blood transfusion.

Solid-phase extraction and quantitative measurement of omega and omega-1 metabolites of JWH-018 and JWH-073 in human urine.

The aminoalkylindole agonists JWH-018 and JWH-073 are contained in "K2/SPICE" products sold as "legal marijuana". Previous human metabolic studies have identified (ω)-hydroxyl and (ω)-carboxyl metabolites as biomarkers that are indicative of product use. However, other primary metabolites exhibiting similar chromatographic properties and mass spectra are also excreted in human urine. Analytical standards were used in this study to identify new primary metabolites as (ω-1)-hydroxyl derivatives of JWH-018 and JWH-073. The liquid chromatography tandem mass spectrometry (LC-MS/MS) procedure, coupled with an automated solid-phase extraction procedure incorporating deuterium-labeled internal standards, provides rapid resolution of the (ω)- and (ω-1) metabolites with adequate sensitivity, precision, and accuracy for trace analysis in human urine. Results from four urine specimens collected after individuals reportedly self-administered either JWH-018 or a mixture of JWH-018 and JWH-073 showed the following: (1) all tested metabolites were excreted in high concentrations, (2) (ω)- and (ω-1)-hydroxyl metabolites were exclusively excreted as glucuronic acid conjugates, and (3) ∼5%-80% of the (ω)-carboxyl metabolites was excreted as glucuronic acid conjugates. This is the first report to identify and quantify (ω-1)-hydroxyl metabolites of JWH-018 and JWH-073 and the first to incorporate automated extraction procedures using deuterium-labeled internal standards. Full clinical validation awaits further testing.

Seizure and coma following Kratom (Mitragynina speciosa Korth) exposure.

Reports of toxicity secondary to Kratom are rare and lack of diagnostic testing in human specimens has prevented confirmatory explanation of observed clinical effects. We present a novel case of serious human toxicity following Kratom use confirmed via quantitative analysis of urine by high performance liquid chromatography coupled to electrospray tandem mass spectrometry. A 64 year-old male was witnessed to have a seizure at home following kratom consumption. Upon arrival to the emergency department (ED), the patient was unresponsive. While in the ED, the patient sustained a second seizure. He was intubated to protect his airway. The remainder of his hospital course was uneventful. A urine specimen was collected shortly after admission and sent for analysis. The mitragynine concentration in the urine was 167 ± 15 ng/ml. We report a rare case of Kratom toxicity characterized by a seizure and coma confirmed by urinary analysis of mitragynine by high performance liquid chromatography coupled to electrospray tandem mass spectrometry. The proposed mechanism for this reaction is unclear but suggested mechanisms include adenosine binding or stimulation of adrenergic and/or serotonergic receptors similar to tramadol.