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Haider M, Acevedo-Cajigas C, Ortiz D, Zorrilla CA, Perez J. Persistent Coagulopathy After Synthetic Cannabinoid Use. Cureus 2023; 15:e36156. [PMID: 37065401 PMCID: PMC10101812 DOI: 10.7759/cureus.36156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2023] [Indexed: 03/17/2023] Open
Abstract
Synthetic cannabinoids (SCs) are chemical compounds created and manufactured, without quality control standards or requirements, to mimic tetrahydrocannabinol (THC). They are widely available in the USA, and they are sold under various brand names, including "K2" and "spice." Many adverse effects have been attributed to SCs, but most recently, they have also been associated with bleeding. There have been reported cases around the globe of SCs contaminated with long-acting anticoagulant rodenticide (LAAR) or superwarfarins. They are developed from compounds such as bromethalin, brodifacoum (BDF), and dicoumarol. LAAR exhibits their mechanism as a vitamin K antagonist inhibiting vitamin K 2,3-epoxide reductase, preventing activation of vitamin K1 (phytonadione). Therefore, reducing the activation of clotting factors II, VII, IX, and X and proteins C and S. In contrast to warfarin, BDF has an extremely long-acting biological half-life of 90 days due to minimal metabolism and limited clearance. Here, we report a 45-year-old male who presented to the emergency room with a 12-day history of gross hematuria and mucosal bleeding without previous history of coagulopathy and recurrent SCs use.
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Wiens T, Taylor J, Cole C, Saravia S, Peterson J, Lunda M, Margetta J, D’Heilly P, Holzbauer S, Lynfield R. Lessons Learned From the E-cigarette, or Vaping, Product Use-Associated Lung Injury (EVALI) Outbreak Response, Minnesota, 2019-2020. Public Health Rep 2022; 137:1053-1060. [PMID: 34694926 PMCID: PMC9574319 DOI: 10.1177/00333549211051394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2021] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Electronic cigarette (e-cigarette), or vaping, product use-associated lung injury (EVALI) is a novel noncommunicable disease with an unknown cause. The objective of this analysis was to describe the Minnesota Department of Health's (MDH's) outbreak response to EVALI, including challenges, successes, and lessons learned. METHODS MDH began investigating EVALI cases in August 2019 and quickly coordinated an agencywide response. This response included activating the incident command system; organizing multidisciplinary teams to perform the epidemiologic investigation; laboratory testing of e-cigarette, or vaping, products (EVPs) and clinical specimens; and collaborating with partners to gather information and develop recommendations. RESULTS MDH faced numerous investigational challenges during the outbreak response of EVALI, including the need to gather information on unregulated and illicit substances and their use and collecting information from minors and critically ill people. MDH laboratorians faced methodologic challenges in characterizing EVPs. Despite these challenges, MDH epidemiologists successfully collaborated with the MDH public health laboratory, law enforcement, partners with clinical and toxicology expertise, and local and national public health partners. PRACTICE IMPLICATIONS Lessons learned included ensuring the state public health agency has legal authority to conduct noncommunicable disease outbreak investigations and the necessity of cultivating and using internal and external partnerships, specifically with laboratories that can analyze clinical specimens and unknown substances. The lessons learned may be useful to public health agencies responding to similar public health emergencies. To improve preparedness for the next outbreak of EVALI or other noncommunicable diseases, we recommend building and maintaining partnerships with internal and external partners.
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Affiliation(s)
- Terra Wiens
- Minnesota Department of Health, St. Paul, MN, USA
- Now with Washington State Department of Health, Seattle, WA, USA
| | - Joanne Taylor
- Minnesota Department of Health, St. Paul, MN, USA
- Epidemic Intelligence Service, Division of Scientific Education and Professional Development, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Cory Cole
- Minnesota Department of Health, St. Paul, MN, USA
- Council of State and Territorial Epidemiologists, Atlanta, GA, USA
| | | | | | - Mark Lunda
- Minnesota Department of Health, St. Paul, MN, USA
| | | | | | - Stacy Holzbauer
- Minnesota Department of Health, St. Paul, MN, USA
- Center for Preparedness and Response, Centers for Disease Control and Prevention, Atlanta, GA, USA
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van Breemen RB, Hafner JW, Nosal DG, Feinstein DL, Rubinstein I. Unmet clinical laboratory need in patients hospitalized for acute poisoning from long-acting anticoagulant rodenticides. TOXICOLOGY COMMUNICATIONS 2021; 5:93-96. [PMID: 34458660 PMCID: PMC8388241 DOI: 10.1080/24734306.2021.1925444] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
The importance of real-time, quantitative toxicology data available for physicians treating poisoned patients was illustrated during the 2018 outbreak in Illinois of severe coagulopathy caused by inhaling illicit synthetic cannabinoids products contaminated with commercially-available brodifacoum, difenacoum, and bromadiolone, three potent, long-acting anticoagulant rodenticides (LAARs). Identification and quantification of these life-threatening toxins in blood samples of hospitalized patients required toxicology testing with liquid chromatography-tandem mass spectrometry (LC-MS/MS) that was not available in clinical laboratories of hospitals at the time of the outbreak. This highly-sensitive, quantitative assay can provide critical information to guide patient care during and after hospitalization, including identification of offending LAARs, estimates of the ingested dose, and dosage and discontinuation of oral vitamin K1 therapy after hospital discharge once plasma LAARs concentrations decreased to a safe level (<10 ng/mL). Accordingly, we propose an action plan to enable treating physicians to quantify plasma concentrations of several LAARs simultaneously in poisoned patients. It involves rapid (<15 min), sensitive, and validated LC-MS/MS methods developed, tested and validated in our laboratory. This will allow treating physicians to request quantitative plasma LAARs testing, report test results in the patient's hospital discharge summary, and recommend regular monitoring of plasma LAARs concentrations in the outpatient setting.
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Affiliation(s)
| | - John W Hafner
- Department of Emergency Medicine, University of Illinois, Peoria, IL, USA
| | - Daniel G Nosal
- Linus Pauling Institute, Oregon State University, Corvallis, OR, USA
| | - Douglas L Feinstein
- Department of Anesthesiology, University of Illinois, Chicago, IL, USA.,Jesse Brown VA Medical Center, Chicago, IL, USA
| | - Israel Rubinstein
- Jesse Brown VA Medical Center, Chicago, IL, USA.,Department of Medicine, University of Illinois, Chicago, IL, USA
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Roberts DM, Premachandra KH, Chan BS, Auld R, Jiranantakan T, Ewers C, McDonald C, Shaw V, Brown JA. A cluster of lysergic acid diethylamide (LSD) poisonings following insufflation of a white powder sold as cocaine. Clin Toxicol (Phila) 2021; 59:969-974. [PMID: 33849370 DOI: 10.1080/15563650.2021.1904140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Adulteration, substitution or contamination of illicit substances can have clinically significant implications when other illicit substances are included. Such circumstances can present as clusters of poisonings, including severe toxicity and death following exposure to unexpected illicit substances. We report a cluster of laboratory-confirmed lysergic acid diethylamide (LSD) in a powder that was sold as cocaine and used recreationally. METHODS The Prescription, Recreational and Illicit Substance Evaluation (PRISE) program established by the New South Wales Ministry of Health includes State-based hospital toxicology services, Poisons Information Centre, Forensic & Analytical Science Service and emergency services to identify clusters of severe and unusual toxicity associated with substance use. PRISE criteria include a known cluster (geographically or situationally related) of people with acute severe toxicity, especially when accompanied by a toxidrome that is inconsistent with the history of exposure. A timely comprehensive drug screen and quantification is performed in eligible cases and the results are related to the clinical features. The need for a public health response is then considered. Four individuals inhaled a white powder that was sold as cocaine and developed severe toxicity that was not consistent with cocaine which prompted transfer to hospital for further management. RESULTS LSD was confirmed in four subjects, and the concentrations in 3 of the individuals were 0.04-0.06 mg/L which are among the highest reported in the literature. Common clinical features were hallucinations, agitation, vomiting, sedation, hypertension, and mydriasis. One subject required intubation and admission to the intensive care unit, two required overnight admission, and the fourth was discharged following oral diazepam after observation. No subject suffered persistent injury. CONCLUSIONS A close working relationship between pre-hospital emergency services, hospital-based clinical services, public health authorities, and analytical laboratories appears to be advantageous. Favourable clinical outcomes are observed from LSD poisoning despite high exposures with good supportive care.
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Affiliation(s)
- Darren M Roberts
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Darlinghurst, Australia.,St Vincent's Clinical School, University of New South Wales, Darlinghurst, Australia.,NSW Poisons Information Centre, Sydney Children's Hospitals Network, Westmead, Australia.,Drug Health Services, Royal Prince Alfred Hospital, Camperdown, Australia
| | - Kulanka H Premachandra
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Darlinghurst, Australia.,St Vincent's Clinical School, University of New South Wales, Darlinghurst, Australia
| | - Betty S Chan
- NSW Poisons Information Centre, Sydney Children's Hospitals Network, Westmead, Australia.,Clinical Toxicology Unit and Emergency Department, Prince of Wales Hospital, Randwick, Australia
| | - Robin Auld
- Centre for Alcohol and Other Drugs, NSW Ministry of Health, St Leonards, Australia
| | - Thanjira Jiranantakan
- NSW Poisons Information Centre, Sydney Children's Hospitals Network, Westmead, Australia.,Drug Health Services, Royal Prince Alfred Hospital, Camperdown, Australia.,Centre for Alcohol and Other Drugs, NSW Ministry of Health, St Leonards, Australia.,Edith Collins Centre, Central Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Christopher Ewers
- Illicit Drugs Analysis Unit, NSW Health Pathology, Forensic & Analytical Science Service, Lidcombe, Australia
| | - Catherine McDonald
- Forensic Toxicology, NSW Health Pathology, Forensic & Analytical Science Service, Lidcombe, Australia
| | - Vanessa Shaw
- Forensic Toxicology, NSW Health Pathology, Forensic & Analytical Science Service, Lidcombe, Australia
| | - Jared A Brown
- NSW Poisons Information Centre, Sydney Children's Hospitals Network, Westmead, Australia.,Centre for Alcohol and Other Drugs, NSW Ministry of Health, St Leonards, Australia
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Peng H, Shahidi F. Cannabis and Cannabis Edibles: A Review. JOURNAL OF AGRICULTURAL AND FOOD CHEMISTRY 2021; 69:1751-1774. [PMID: 33555188 DOI: 10.1021/acs.jafc.0c07472] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Cannabis is an excellent natural source of fiber and various bioactive cannabinoids. So far, at least 120 cannabinoids have been identified, and more novel cannabinoids are gradually being unveiled by detailed cannabis studies. However, cannabinoids in both natural and isolated forms are especially vulnerable to oxygen, heat, and light. Therefore, a diversity of cannabinoids is associated with their chemical instability to a large extent. The research status of structural conversion of cannabinoids is introduced. On the other hand, the use of drug-type cannabis and the phytocannabinoids thereof has been rapidly popularized and plays an indispensable role in both medical therapy and daily recreation. The recent legalization of edible cannabis further extends its application into the food industry. The varieties of legal edible cannabis products in the current commercial market are relatively monotonous due to rigorous restrictions under the framework of Cannabis Regulations and infancy of novel developments. Meanwhile, patents/studies related to the safety and quality assurance systems of cannabis edibles are still rare and need to be developed. Furthermore, along with cannabinoids, many phytochemicals such as flavonoids, lignans, terpenoids, and polysaccharides exist in the cannabis matrix, and these may exhibit prebiotic/probiotic properties and improve the composition of the gut microbiome. During metabolism and excretion, the bioactive phytochemicals of cannabis, mostly the cannabinoids, may be structurally modified during enterohepatic detoxification and gut fermentation. However, the potential adverse effects of both acute and chronic exposure to cannabinoids and their vulnerable groups have been clearly recognized. Therefore, a comprehensive understanding of the chemistry, metabolism, toxicity, commercialization, and regulations regarding cannabinoid edibles is reviewed and updated in this contribution.
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Affiliation(s)
- Han Peng
- Department of Biochemistry Memorial University of Newfoundland, St. John's, Newfoundland, Canada A1B 3X9
| | - Fereidoon Shahidi
- Department of Biochemistry Memorial University of Newfoundland, St. John's, Newfoundland, Canada A1B 3X9
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Feinstein DL, Nosal DG, Ramanathan S, Zhou J, Chen L, Hershow RC, van Breemen RB, Wright E, Hafner JW, Rubinstein I. Effects of vitamin K1 treatment on plasma concentrations of long-acting anticoagulant rodenticide enantiomers following inhalation of contaminated synthetic cannabinoids. Clin Toxicol (Phila) 2019; 58:716-724. [PMID: 31736367 DOI: 10.1080/15563650.2019.1687903] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background: An outbreak of synthetic cannabinoid (SC)-associated coagulopathy and bleeding in Illinois, USA was determined to be due to inhalation of SC contaminated with brodifacoum (BDF), difenacoum (DiF), and bromadiolone (BDL), highly potent long-acting anticoagulant rodenticides (LAARs). Treatment with high-dose vitamin K1 (VK1) prevented mortality; however, plasma LAAR levels were not measured risking recurrence of coagulopathy and bleeding due to premature discontinuation. The goal of this study was to determine if plasma LAAR levels were reduced following standard of care treatment to normalize coagulopathy.Methods: Blood samples were collected from a cohort of 32 patients, and ultra-high performance liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS) analysis used to quantify plasma LAAR levels including enantiomers.Results: BDF was detected in 31 samples; 30 also contained DiF and 18 contained BDL. Initial plasma levels were 581 ± 87, 11.0 ± 1.9, and 14.9 ± 5.9 ng/mL for BDF, DiF, and BDL, respectively (mean ± SE). At discharge plasma, BDF levels remained elevated at 453 ± 68 ng/mL. Plasma half-lives for BDF, DiF, and BDL were 7.5 ± 1.3, 7.2 ± 1.9, and 1.8 ± 0.3 days, respectively. The half-life for trans-BDF enantiomers (5.7 ± 0.8 days) was shorter than for cis-enantiomers (7.6 ± 1.9 days). BDF half-lives were shorter, and coagulopathy normalized faster in patients receiving intravenous VK1 as compared to oral VK1. Patients prescribed VK1 at discharge had fewer re-admittances.Conclusions: These results demonstrate that plasma LAAR levels at discharge were elevated in poisoned patients despite normal coagulation, and that the route of VK1 administration affected LAAR pharmacokinetics and INR normalization. We propose plasma LAAR levels and coagulation be monitored concomitantly during follow-up of patients with LAAR poisoning. KEY POINTSIn patients treated with high-dose vitamin K1 for LAAR poisoning, plasma levels remained 40-fold above safe levels upon discharge from hospital.LAAR half-lives, normalization of coagulopathy, and readmittances were reduced by treatment with intravenous vitamin K1.
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Affiliation(s)
- Douglas L Feinstein
- Jesse Brown VA Medical Center, Chicago, IL, USA.,Department of Anesthesiology, University of Illinois, Chicago, IL, USA
| | - Daniel G Nosal
- Linus Pauling Institute, Oregon State University, Corvallis, OR, USA
| | - Swetha Ramanathan
- Division of Epidemiology and Biostatistics, University of Illinois, Chicago, IL, USA
| | - Jifang Zhou
- College of Pharmacy, University of Illinois, Chicago, IL, USA
| | - Luying Chen
- Linus Pauling Institute, Oregon State University, Corvallis, OR, USA
| | - Ronald C Hershow
- Division of Epidemiology and Biostatistics, University of Illinois, Chicago, IL, USA
| | | | - Erik Wright
- Department of Emergency Medicine, University of Illinois, Peoria, IL, USA
| | - John W Hafner
- Department of Emergency Medicine, University of Illinois, Peoria, IL, USA
| | - Israel Rubinstein
- Jesse Brown VA Medical Center, Chicago, IL, USA.,Department of Medicine, University of Illinois, Chicago, IL, USA
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