The unseen cloud: a survey of vaping practices and the acquisition of vaping products within the UK.

BACKGROUND: Vaping of cannabinoid-based products and informal acquisition of vaping products were associated with the outbreak of E-cigarette or vaping associated lung injury (EVALI) in the USA. Current prevalence of cannabinoid-based vaping within the UK is not known and literature regarding the acquisition of vaping products is limited. AIM: To estimate the prevalence of nicotine-based, nicotine-free and cannabinoid-based product vaping within the UK and to determine where vaping products are acquired. DESIGN AND METHODS: A voluntary online survey of individuals aged 16 and over within the UK was conducted using a convenience sample. Data were collected on respondent demographics, smoking/vaping history and acquisition of e-liquids/products. RESULTS: A total of 2478 responses were included. Median age 45 years (interquartile range 35-57). Prevalence of current vaping of nicotine-based e-liquids, nicotine-free e-liquids and cannabinoid-based products was 14.4%, 11.2% and 5.49%, respectively. Current nicotine-based and nicotine-free vaping was most prevalent in 25-34 years olds (22.4% and 19.2% of respondents). Current cannabinoid-based vaping was most prevalent in 16-24 years olds. The most common 'ever' used cannabinoid-based products were cannabidiol oil/cannabigerol oil and cannabis leaves (4.8%). Specialist vaping stores were the most common source of 'ever' acquisition for all products. 36.8% and 40.5% of respondents who had ever vaped nicotine-based and nicotine-free e-liquids reported prior acquisition from informal sources. CONCLUSION: This survey reported a higher prevalence of current cannabinoid-based vaping within the UK (5.5%) than previously reported in the USA (2.0%). In addition to the informal acquisition of vaping products as demonstrated within the survey, these results highlight potential underestimation of the risk of EVALI within the UK.

The Emerging Cloud: a survey of vapers, their health and utilization of healthcare within the UK.

BACKGROUND: Recent work in the UK estimated the prevalence of current cannabinoid-based vaping to be higher than in the USA, a factor previously associated with e-cigarette or vaping-associated lung injury (EVALI). Research in the USA has demonstrated that attendances to emergency departments relating to e-cigarettes began to rise before the EVALI outbreak, suggesting that vapers also experience milder forms of vaping-related illness. AIM: Quantify symptom prevalence and healthcare utilization amongst current UK vapers. DESIGN: Voluntary online survey of individuals aged 16 and over within the UK. METHODS: Anonymized data were collected on demographics, vaping/smoking status and vaping substances used. Current vapers were asked about the presence of 10 prevalent symptoms from previous US EVALI case series, healthcare attendances and diagnoses given. Risk-ratios were calculated to compare the likelihood of symptoms and attendances between substances. RESULTS: A total of 2477 complete responses were analysed. In all, 397 respondents were current vapers. Symptom prevalence within the previous 12 months ranged from 3.8% to 30.5% (bloody sputum, cough). Healthcare attendances per symptomatic respondent ranged from 0.1 to 1.4 (bloody sputum, shortness of breath). Current vapers of cannabinoid-based products (alone/in combination) had the most attendances per symptomatic respondent for 9/10 symptoms and were more likely to report symptoms aside from 'cough' (nicotine-free e-liquids [risk ratio = 1.7]). Clinicians reportedly never diagnosed vaping-related illness. CONCLUSIONS: UK vapers experience symptoms previously reported in EVALI cases for which they also seek healthcare. Users of cannabinoid-based products were more likely to report symptoms and accounted for a higher healthcare burden. UK vapers may also experience vaping-related illness that does not meet EVALI case criteria.

Isotonitazene, a novel psychoactive substance opioid, detected in two cases following a local surge in opioid overdoses.

BACKGROUND: Isotonitazene is a novel opioid that was first reported in Europe in 2019. There have been no reports of the detection of isotonitazene in patients presenting to the emergency department with acute drug toxicity. AIM: There was an increase in presentations to our emergency department with acute opioid toxicity in August 2021. We aim to describe this outbreak and provide detail on two cases in which isotonitazene was quantified in serum samples. METHODS: Serum samples were available for comprehensive toxicological analysis for two presentations. Written consent was obtained and the samples were analysed through a Thermo XRS ultrahigh-performance liquid chromatography system, interfaced to a Thermo Q Exactive high-resolution accurate mass spectrometer, operating in heated positive ion electrospray mode. Acquired data were processed using Toxfinder software (Thermo) against a regularly updated in-house database. RESULTS: There was an increase in acute opioid presentations to our emergency department from a median of 10 per month to 36 in August 2021. Twenty were treated with naloxone, and 23 were admitted to the hospital for observation and treatment. Serum sample analysis from two patients with acute opioid toxicity responsive to naloxone detected the presence of isotonitazene (0.18 and 0.81 ng/ml). CONCLUSION: We report a cluster of acute opioid toxicity presentations to our Emergency Department with detection of isotonitazene in two cases. Analytical screening is important in determining the presence of novel psychoactive substances (NPS) and to help inform the public health of the implications of NPS use, particularly during clusters of acute recreational drug toxicity presentations.

Doctors' knowledge of the appropriate use and route of administration of antidotes in the management of recreational drug toxicity.

BACKGROUND: Specific antidotes (eg, naloxone, flumazenil, cyproheptadine and benzodiazepines) are available for the management of certain recreational drug-induced toxicities. Some controversies surround the use of some of these antidotes, especially flumazenil in benzodiazepine toxicity. There are no previously published data on doctors' knowledge of the use of these specific antidotes. METHODS: A questionnaire survey was designed to determine internal/emergency medicine doctors' knowledge of the appropriate use of antidotes in the management of clinical scenarios of acutely poisoned patients. For nine simulated clinical scenarios of acute toxicity from recreational drugs (benzodiazepines, cocaine, N-methyl-L-(3,4-methylene-dioxyphenyl)-2-aminopropane (MDMA)-induced serotonin toxicity and opioids), they were asked to indicate whether the suggested antidote and route of administration were correct. RESULTS: 42 physicians of all grades completed the questionnaire. The mean correct score was 5.4 (SD 1.1) (median 6, interquartile range 5-7). The percentages correct for the various clinical scenarios were 68.3% for opioid toxicity, 81% for benzodiazepine toxicity, 28.6% for MDMA-induced serotonin toxicity and 70.2% for cocaine toxicity. Doctors were more likely to record an answer of "unsure" for the use of cyproheptadine in ST serotonin toxicity (28.6%) compared with the use of the other antidotes (1.4%; p<0.001). CONCLUSION: Knowledge of the appropriate use of antidotes in recreational drug toxicity is not consistent, with poorer knowledge on the use of newer antidotes such as cyproheptadine in serotonin toxicity. Education is required both to increase overall knowledge on the use of specific antidotes in the management of recreational drug-induced toxicity, as well as focusing on newer antidotes such as cyproheptadine.

Analysis of anonymized pooled urine in nine UK cities: variation in classical recreational drug, novel psychoactive substance and anabolic steroid use.

BACKGROUND: Analysis of anonymous pooled urine samples from street urinals has been used to demonstrate time-trends in the detection of classical recreational drugs and novel psychoactive substances (NPS). AIM: This study aimed to expand this to undertake a geographical trend analysis of classical recreational drugs/NPS across UK. METHODS: Samples of anonymous pooled urine were collected from street urinals that had been in place for one night in April 2014 in nine cities across the UK. Collected samples were then analysed for the presence of recreational drugs, NPS anabolic steroids using high-performance liquid chromatography coupled to high-resolution accurate mass full-scan mass spectrometry and gas chromatography coupled to electron impact ionization mass spectrometry operating in selected ion monitoring and full-scan modes. RESULTS: Ten classical recreational drugs, nine NPS and four anabolic steroids were detected across the nine cities; the range of detection was from 1 in Leeds to 14 in London. The most common classical drugs were cocaine (9 cities) and 3,4-methylenedioxy-methamphetamine (8 cities); the most common NPS was 4-methylmethcathinone (5 cities). In addition there was variation in the detection of NPS, with methylhexaneamine detected only in Bristol and London, piperazines (3-trifluoromethylphenylpiperazine and 1-benzylpiperazine) and pentedrone only detected in Birmingham and the cathinone methylone only detected in London. CONCLUSIONS: There is variability in the detection of classical recreational drugs, NPS and anabolic steroids across UK, likely reflecting variation in their use. This technique can be used to supplement drug use surveys to determine geographical and time trends in the use of these substances. This is important to ensure appropriate targeting of drug-related interventions.

Cell proliferation within the growth plate of the tich mouse.

The pattern of chondrocyte proliferation was studied in the proximal tibial growth plate of tich mice (gene symbol tch), a recessive mouse mutant, which is coisogenic with the A.TL strain. Specimens were qualitatively studied at time points of 2, 3, 4, 6, and 8 weeks of age by bromodeoxyuridine labeling of cell division and routine histology. At 2 weeks, when the lesion appeared as a full-width thickening of the growth plate, a greater proportion of cells appeared positively labeled in the proliferative zone. This concavity in the central portion of the growth plate became progressively more focal between 3 and 4 weeks to give a "tongue" of unresorbed, noncalcified cartilage in the central region of the tich growth plate. BrdUrd labeling indicated that the appearance of the cartilage tongue corresponded with increased cell division in the central region of the growth plate. At the same time, a "second" zone of cell division formed, within the zone of hypertrophy, such that labeled cells appeared to be set among chondrocytes with hypertrophic morphology. At stages after 4 weeks of age the focal feature disappeared as the growth plate returned to more normal morphology by maturity. It seems that this unique "second" zone of dividing cells may contribute to formation of an elongation of the nonresorbed tongue of cartilage. However, it is not likely to be the primary defect since growth plate changes were apparent at earlier stages.

The production of human monoclonal autoantibodies from patients with rheumatoid arthritis by the EBV-hybridoma technique.

Rheumatoid lymphocytes tend to transform 'spontaneously' in vitro because of prior infection with Epstein Barr virus (EBV). They are particularly difficult to use in experiments involving cell hybridisation, because in the conventional half-HAT system unfused transformed cells may be confused with hybrids. We describe how the HAT-sensitive, ouabain-resistant human B lymphoblastoid cell line KR4, originally developed to 'rescue' EBV induced B cell clones, can be fused successfully with peripheral blood lymphocytes from patients with rheumatoid arthritis to produce unequivocal hybrids.

Cross-reactivity between solid-phase immunoassay plates and intermediate filaments demonstrated by human monoclonal antibodies.

While screening supernatants of human-human hybridomas for rheumatoid factor and anti-cellular activity we found that a significant number of supernatants which react with the Falcon-polyvinyl chloride immunoassay plate used in an enzyme-linked immunosorbent rheumatoid factor assay also react with intracellular intermediate filaments.

Binding of monomeric and aggregated immunoglobulin to enzymes. A source of artefact in antibody assays.

Pepsinogen has previously been shown to bind non-specifically to immune complexes and aggregated immunoglobulins. We demonstrate here using a solid-phase immunoassay that immunoglobulins aggregated by heat or glutaraldehyde bind non-specifically to several different enzymes. Some of these, including pepsinogen (marketed as pepsin), hyaluronidase and trypsin, are used in the breakdown of tissues or biochemical preparations during the preparation of antigens. Contamination of impure antigens by enzyme is likely to lead to products which bind non-specifically to immune complexes. This can cause misidentification of complexes as antibodies. We recommend that all tests for specific antibody involving the use of antigens prepared by these or other enzymes should include a control with aggregated immunoglobulin substituted for the test serum.

Biomarkers of aging: tissue markers. Future research needs, strategies, directions and priorities.

Objective tests that allow early detection of deleterious changes with age are necessary to develop treatments enhancing the health span--the length of healthy life. Here we report tests of eight biological systems that can be performed in mice with no harm to the subjects. Male and female B6, CBA and F1 mice were used. While most test results correlated with chronological age in most genotypes, none predicted subsequent longevities in more than two genotypes. Surprisingly, the open field activity test that most consistently predicted longevities, did not correlate with chronological age. Six tests predicted beneficial effects of food restriction in F1 males, but only one correctly predicted the deleterious effects of the same food restriction regimen in B6 males. These results suggest that different biological systems age at different rates, that rates are affected by genotype and that an anti-aging treatment beneficial in one genotype may be harmful in another.

Physiological and behavioral correlates of lifespan in aged C57BL/6J mice.

Physiological and behavioral measurements were made in a cohort of 29-month-old male C57BL/6J mice to determine whether any correlated significantly with lifespan. Significant linear relationships with lifespan were found among the physiological measures, including hematocrit and hemoglobin levels and collagen denaturation rate; however, body weight failed to be a significant predictor of survival. Among the behavioral variables studied, significant quadratic relationships with lifespan were found for exploratory activity and passive avoidance learning, while performance on a rotorod and a tightwire showed no significant relationships with lifespan. Through the use of multiple regression techniques, about one-third of the variance in lifespan could be explained by a combination of physiological variables, and about two-fifths could be explained by a combination of behavioral variables.

L-deprenyl treatment in aged mice slightly increases life spans, and greatly reduces fecundity by aged males.

Male and female B6D2F1 (C57BL/6J x DBA/2J)F1 and B6CBAF1 (C57BL/6J x CBA/CaHT6J)F1 mice were injected subcutaneously 3 times a week with L-deprenyl (0.25 mg/kg) starting at mean ages of 26 months and 18.5 months, respectively. Life spans of aging mice were increased 6-9% by the drug. While none of the life span effects were significant for a single genotype and gender, life spans were significantly longer in L-deprenyl-treated animals (p = .011) when all data were combined. L-deprenyl-injected mice consumed about the same amounts of food as controls: L-deprenyl 3.1 g/day, control 3.3 g/day, after 7 months of treatment. There were no significant effects of L-deprenyl on measures of changes with age in the following biological systems: activity, excitement, red blood cell mass, collagen denaturation rate, and wound healing rate. L-deprenyl-treated B6CBAF1 males and females were significantly heavier than controls after 4-6 months of treatment. To measure fecundity, B6CBAF1 males at an average age of 750 days were each caged with two young B6 females; 10 of 17 L-deprenyl-injected males sired an average of 31.3 pups per male, while 14 of 24 controls sired 82.1 pups per male.

Maximum life spans in mice are extended by wild strain alleles.

The genes that control basic aging mechanisms in mammals are unknown. By using two four-way crosses, each including a strain derived from wild, undomesticated stocks, we identified two quantitative trait loci that extend murine life spans by approximately 10%. In one cross, the longest-lived 18% of carriers of the D8Mit171 marker allele from the MOLD/Rk strain, Mus m. molossinus, outlived the longest lived 18% of noncarriers by 129 days (P = 5.4 x 10(-5)); in a second cross, carriers of the D10Mit267 allele from the CAST/Ei strain, Mus m. castaneus, outlived noncarriers by 125 days ( P = 1.6 x 10(-6)). In both crosses, P < 1.0 x 10(-4 )is considered significant. Because these life span increases required that all essential biological systems function longer than normal, these alleles most likely retarded basic aging mechanisms in multiple biological systems simultaneously.

Factors influencing the cytotoxicity of anti-bacterial sera for lymphocytes from ankylosing spondylitis patients.

Rabbit antisera to certain strains of Gram-negative bacteria are reported to be cytotoxic for the lymphocytes of about 80% of HLA-B27 positive patients with ankylosing spondylitis (AS) but not for the lymphocytes of healthy HLA-B27 positive individuals. The lymphocytes of normal individuals can, however, be made susceptible to lysis by antibacterial sera by incubation in spent supernatant from appropriate bacterial cultures. In an attempt to explain the failure of certain laboratories to reproduce these results we have tested a number of variables in the 51Cr-release complement-dependent cytotoxicity assay. We conclude that AS patients in London and Sydney carry the same antigen, that several different incubation media can be used for both the cytotoxicity assay of HLA-B27 positive AS cells and modification of normal B27 positive cells and that the cells used may be collected either in heparin containing media or after defibrination. Major requirements for success include a healthy sample of lymphocytes (preferably at a fairly high concentration), suitable antiserum from a rabbit repeatedly immunised with large numbers of bacteria, appropriate complement and efficient technique. However, as we have failed to repeat this test consistently in London, even using materials tested in this study, it seems that another, probably non-biological, factor is also important.

Genetics of age-related hearing loss in mice: I. Inbred and F1 hybrid strains.

The auditory-evoked brainstem response (ABR) was used to assess hearing loss in five inbred strains of mice and all ten combinations of F1 hybrids. The inbred strains are CBA/H-T6J (CH), DBA/2J (D2), C57BL/6J (B6), BALB/cByJ (BY) and WB/ReJ (WB). The F1 hybrids are CHD2, CHB6, CHBY, CHWB, D2B6, D2BY, D2WB, B6BY, B6WB, and BYWB. At middle age (12, 16 months), mice were tested with click stimuli. At a relatively old age (23 months, near inbreds' median life span), they were tested with both click and tone-pip stimuli. The CH mice and their four F1 hybrid strains exhibit lower thresholds than the other strains, with the F1 strains being most sensitive (i.e., hybrid vigor). The D2 inbred and the three D2 F1 hybrids (excluding CHD2) exhibit the earliest and most severe hearing losses. The B6, BY and WB inbred strains exhibit severe hearing losses between 16 and 23 months of age; however, the B6BY, B6WB and BYWB F1 hybrids have significantly lower thresholds than their parental strains (genetic complementation). These data support a genetic model for recessive alleles at three different loci which contribute to age-related hearing loss. The CH mice have none of the recessive alleles, and the D2 mice are homozygous recessive for all three; the B6, BY and WB inbred strains are homozygous recessive respectively for one of the three loci.

Genetics of age-related hearing loss in mice. II. Strain differences and effects of caloric restriction on cochlear pathology and evoked response thresholds.

The effects of genotype and diet on age-related hearing loss were evaluated using auditory brainstem response (ABR) thresholds and post-mortem cochlear histopathology in 5 inbred mouse strains, CBA/H-T6J (CH), DBA/2J (D2), C57BL/6J (B6), BALB/cByJ (BY) and WB/ReJ (WB), and their 10 F1 hybrid strains. The mice had been maintained since weaning on either a high-energy (HE) control diet or low-energy (LE) calorically restricted diet. ABR thresholds were obtained when the mice were 23 months old; the mice were allowed to age until they died from natural causes prior to obtaining the histological material. The severity of post-mortem cochlear pathology in mice maintained with the HE diet supports our earlier genetic model which postulated that B6, BY, and WB strains each possessed a different recessive allele causing age-related hearing loss, D2 mice possessed all 3 genes, and CH mice possessed none. The histopathology indicates that the genes act at the cochlear level. Dietary restriction resulted in increased longevity in a number of strains, but age-related changes in cochlear pathology were not ameliorated in any of these; indeed, in some strains long-lived LE mice exhibited severe cochlear degeneration. In strains for which longevity was not extended by caloric restriction, only B6 mice exhibited an ameliorative effect of the LE diet on cochlear pathology. ABRs in 23-month-olds indicated a slowing of age-related hearing loss in LE mice of 3 F1 hybrid strains.

Blastomycosis in wild wolves.

Blastomycosis was fatal to a wild wolf in Minnesota, and serologic evidence of blastomycosis was found in a Wisconsin wolf. No unusual movements were detected in the Minnesota animal from October 1983 through October 1985. However, by early December 1985, this wolf was weak and debilitated, and it perished on 14 December after approaching a human residence.

Epidemiologic study of canine blastomycosis in Wisconsin.

An epidemiologic study was designed to investigate the increasing number of cases of canine blastomycosis being reported in Wisconsin. From January 1980 through July 1982, 200 cases of canine blastomycosis from 39 Wisconsin counties were examined to assess epidemiologic and environmental aspects of this disease. Based on a survey of 176 dog owners, principal disease characteristics for canine blastomycosis were anorexia, lethargy, shortness of breath, chronic cough, and weight loss. The greatest number of cases of canine blastomycosis was in the northwest, north central, northeast, central, and southeast regions of Wisconsin. The northeast and central regions were determined to be new enzootic areas. Sporting breeds accounted for the largest percentage of cases among the various breeds of dogs in Wisconsin. Most of the affected dogs were 3 years old or younger and there was no apparent sexual predilection. Canine blastomycosis was diagnosed more frequently from late spring through late fall. Enzootic areas, except for the southeast region of Wisconsin, were located where the soil was sandy and acid. The results of this study suggested a possible association of enzootic areas with waterways, especially impoundments.

An Internet snapshot study to compare the international availability of the novel psychoactive substance methiopropamine.

CONTEXT: With the increased use of novel psychoactive substances, there is an increasing availability of these substances from Internet-based suppliers. Methiopropamine, first reported in 2011, is a recreational drug available over the Internet. The aim of this study was to investigate availability and cost of methiopropamine in three different countries: the UK, France, and Canada. METHODS: Using the European Monitoring Centre for Drugs and Drug Addiction Internet snapshot methodology, this study, conducted in June 2013, was undertaken in two different languages: in English (the UK and Canada) and in French (France and Canada), using three Internet searching engines: " google.co.uk ", " google.fr " and " google.ca ". RESULTS: A total of 62 sites were found, most of them were found from the English searches. 45% of the suppliers seemed to originate from the UK. The prices of methiopropamine were comparable between suppliers, no matter which search engine or language was used. The cost of a unit of methiopropamine was inversely related to the purchased quantity, going from 19.49 ± 0.15 GBP per gram for a purchase amount of 500 mg to 3.54 ± 0.13 GBP per gram for a purchase amount of 1 kg. DISCUSSION: The results of the present study demonstrate that the sale of methiopropamine has the potential to reach users across the world. It also appears to support that snapshot studies could be used for toxicovigilance across different countries, by studying the Internet market of novel psychoactive substances. CONCLUSION: To date, snapshot studies, used to monitor the Internet novel psychoactive substances market, have only been undertaken in Europe. We have shown that the flexibility of this methodology enables comparison of the online activity of drug sellers between different countries and continents and that, at least for methiopropamine, the UK is the predominant source for Internet supply.

Trend analysis of anonymised pooled urine from portable street urinals in central London identifies variation in the use of novel psychoactive substances.

CONTEXT: There is increasing interest in the analysis of waste water at sewage treatment plants to monitor recreational drug use. This technique is limited for novel psychoactive substances (NPS) due to limited knowledge on their human and bacterial metabolism and stability in waste water. Small studies have reported the detection of NPS using pooled anonymous urine samples, which eliminates some of these potential confounders. OBJECTIVE: To determine patterns of recreational drug, including NPS, use by confirming their presence in analysis of pooled urine from portable street urinals across a wide geographical area in central London over a 6-month period. MATERIALS AND METHODS: Pooled anonymous urine samples were collected from 12 four-bay stand-alone portable urinals distributed once a month across central London for six consecutive months. Samples were analysed using high-performance liquid chromatography coupled to high-resolution accurate mass spectrometry (LC-HRAM-MS); acquired data were processed against target compound databases. RESULTS: With regards to Classical Recreational Drugs, there was consistency of detection of cathine, cocaine, morphine, MDMA over the 6 months, with variability of detection of amphetamine, ketamine and cannabis. With regards to NPS, a total of 13 NPS were detected during the six months. Mephedrone and methylhexaneamine were detected consistently each month. Other commonly detected NPS included methiopropamine (5 months), pipradrol (4 months), cathinone (4 months), 5-(2-aminopropyl)benzofuran (3 months) and 4-methyethcathinone (3 months). Of note, methoxetamine and the synthetic cannabinoid receptor agonists were not detected in any samples. DISCUSSION: Previous studies using the same method detected three and five NPS in a nightclub and pissoir setting, respectively, on a single night. The longer sampling time of 6 months has allowed detection of 13 NPS. Of note, mephedrone showed the least month-to-month variation in detection over the 6-month sampling period. With regards to classical recreational drugs, those detected were consistent with use-data from UK population surveys. The only exception is amphetamine which these surveys have shown a steady decline in use since 1996 but our study showed some variation in the frequency of its detection. However, the sampling period was too short and a longer study is needed to detect the trend in decreasing use. CONCLUSION: This study demonstrates that analysis of anonymous pooled urine samples from stand-alone urinals can be used to detect and monitor trends in the use of classical recreational drugs and NPS in a large city centre over time. This technique has the potential to be a novel key indicator alongside other existing indicators to provide a more robust picture of the use of recreational drugs including NPS.