Severe liver dysfunction in a toddler receiving nonprescription phytocannabinoid.

BACKGROUND: Nonprescription cannabis products are becoming widely available and being promoted for various health conditions. Safety profile of these products apart from psychoactive effects has not been studied and published well. Liver dysfunction is well described in literature with high doses of recreational tetrahydrocannabinol and cannabidiol products but not with nonprescription phytocannabinoids products used for various medicinal values. CASE SUMMARY: A 2-year-old unimmunized male with infantile spasms and refractory seizures, managed with clobazam and zonisamide, presented for respiratory illness and incidentally diagnosed with severe liver dysfunction with elevated coagulation markers. He did not manifest any clinical signs of liver failure. On further review, it was found that parents were using nonprescription phytocannabinoids (hemp extract) for his neurological condition. He required supportive care for his liver dysfunction, and liver enzymes down trended gradually after holding his phytocannabinoid products. The World Health Organization-Uppsala Monitoring Centre approach puts the presentation as probable/likely category of adverse reaction for liver dysfunction with phytocannabinoid ingestion. PRACTICAL IMPLICATIONS: The case we present shows the detrimental effects of over-the-counter phytocannabinoid products, which could point toward the role of phytocannabinoids in this pathophysiology. The case highlights the importance of awareness of potential life-threatening consequences of these products and educating the patient and the caregivers of these risks. The case also emphasizes the need for serial liver enzymes monitoring for patients receiving these therapies as well as extensive research focusing on safety profile of these products in terms of different organ system affection other than their psychoactive potential.

Histological confirmation of needle tip position during ultrasound-guided interscalene block: a randomized comparison between the intraplexus and the periplexus approach.

PURPOSE: Ultrasound-guided interscalene block can be performed using either periplexus or intraplexus needle placement. In this novel study, we histologically examined the needle tip position in relation to the neural tissues with the two techniques. Our objective was to investigate the variable risk of subepineurial needle tip placement resulting from the two ultrasound-guided techniques. METHODS: In an embalmed cadaveric model, periplexus or intraplexus interscalene injections were performed with the side, order, and technique assigned randomly. Under real-time ultrasound guidance, the block needle was placed next to the hyperechoic layer of the plexus (periplexus) or between the hypoechoic nerve roots (intraplexus). Once positioned, 0.1 mL of black acrylic ink was injected. The brachial plexus tissues were then removed and histology sections were prepared and then coded in order to blind two reviewers to group allocation. The area of ink staining was used to determine needle tip location, and the groups were compared for the presence of subepineurial ink. RESULTS: Twenty-six cadavers had each of the blocks performed on either brachial plexus (i.e., 52 injections). No subepineurial ink deposits were observed in the periplexus group (0%), but subepineurial ink deposition was observed in 3/26 (11.5%) intraplexus injections (odds ratio, 0; 95% confidence interval, 0 to 2.362; P = 0.235). Furthermore, in the intraplexus group, two (of the three) subepineurial ink deposits were observed under the perineurium. CONCLUSION: Although our study was somewhat underpowered due to a lower than previously reported rate of subepineurial needle tip positioning, our results suggest that there may be an increased likelihood of subepineurial needle tip position with the intraplexus approach. The periplexus technique resulted in no subepineurial spread of ink, suggesting that this approach may be less likely to result in mechanical trauma to nerves from direct needle injury.

Qualitative Study on Safe and Effective Handover Information during a Rapid Response Team Encounter.

Introduction: A rapid response team (RRT) evaluates and manages patients at risk of clinical deterioration. There is limited literature on the structure of the rapid response encounter from the floor to the intensive care unit team. We aimed to define this encounter and examine provider experiences to elucidate what information healthcare staff need to safely manage patients during an RRT evaluation. Methods: This phenomenological qualitative study included 6 focus groups (3 in-person and 3 virtually) organized by provider type (nurses, residents, fellows, attendings), which took place until thematic saturation was reached. Two authors inductively coded transcripts and used a quota sampling strategy to ensure that the focus groups represented key stakeholders. Transcripts were then analyzed to identify themes that providers believe influence the RRT's quality, efficacy, and efficiency and their ability to manage and treat the acutely decompensating pediatric patient on the floor. Results: Transcript coding yielded 38 factors organized into 8 themes. These themes are a summary statement or recap, closed-loop communication, interpersonal communication, preparation, duration, emotional validation, contingency planning, and role definition. Conclusions: The principal themes of utmost importance at our institution during an RRT encounter are preparation, a brief and concise handoff from the floor team, and a summary statement from the intensive care unit team with contingency planning at the end of the encounter. Our data suggest that some standardization may be beneficial during the handoff.

PFAS surveillance in abiotic matrices within vital aquatic habitats throughout Florida.

Per- and polyfluoroalkyl substances (PFAS) are a group of manufactured chemicals that are resistant to degradation and thus persistent in the environment. The presence, uptake, and accumulation of PFAS is dependent upon the physiochemical properties of the PFAS and matrix, as well as the environmental conditions since the time of release. The objective of this study was to measure the extent of PFAS contamination in surface water and sediment from nine vulnerable aquatic systems throughout Florida. PFAS were detected at all sampling locations with sediment exhibiting greater PFAS concentrations when compared to surface water. At most locations, elevated concentrations of PFAS were identified around areas of increased human activity, such as airports, military bases, and wastewater effluents. The results from the present study highlight the ubiquitous presence of PFAS in vital Florida waterways and filled an important gap in understanding the distribution of PFAS in dynamic, yet vulnerable, aquatic environments.

Aquatic Vegetation, an Understudied Depot for PFAS.

Per- and polyfluoroalkyl substances (PFAS) are a class of manufactured chemicals that have been extensively utilized worldwide. We hypothesize that the presence, uptake, and accumulation of PFAS in aquatic vegetation (AV) is dependent upon several factors, such as the physiochemical properties of PFAS and proximity to potential sources. In this study, AV was collected from eight locations in Florida to investigate the PFAS presence, accumulation, and spatiotemporal distribution. PFAS were detected in AV at all sampling locations, with a range from 0.18 to 55 ng/g sum (∑)PFAS. Individual PFAS and their concentrations varied by sampling location, time, and AV species. A total of 12 PFAS were identified, with the greatest concentrations measured in macroalgae. The average bioconcentration factor (BCF) among all samples was 1225, indicating high PFAS accumulation in AV from surface water. The highest concentrations, across all AV types, were recorded in the Indian River Lagoon (IRL), a location with a history of elevated PFAS burdens. The present study represents the first investigation of PFAS in naturally existing estuarine AV, filling an important gap on PFAS partitioning within the environment, as well as providing insights into exposure pathways for aquatic herbivores. Examining the presence, fate, and transport of these persistent chemicals in Florida's waterways is critical for understanding their effect on environmental, wildlife, and human health.