Repeated subcutaneous administrations of krokodil causes skin necrosis and internal organs toxicity in Wistar rats: putative human implications

Bisphosphonates and osteonecrosis of the jaws: Clinical and forensic aspects

OBJECTIVE

This manuscript aims to provide a comprehensive review of the current knowledge in the pathophysiology, diagnosis, prevention, and other relevant clinical and forensic aspects of a potentially severe complication known as medication-related osteonecrosis of the jaw (MRONJ) while synthesizing state-of-the-art information on bisphosphonates and introducing a possible differential diagnosis.

DESIGN

An extensive search was conducted in PubMed (U.S. National Library of Medicine) without a time or language constraint, focusing on the epidemiology, pathophysiology, risk factors, site specificity, signs and symptoms, differential diagnosis, prevention, and forensic aspects of MRONJ. All types of original articles, reviews, case reports, short communications, opinion articles, guidelines, and letters to editors were considered to produce a complete review on this subject.

RESULTS

MRONJ prevention relies on a multidisciplinary approach and is critical since truly effective treatments are lacking. This therapeutic challenge is partly due to uncertainty regarding this condition's pathophysiology. Differential diagnosis of osteonecrosis of the jaws associated with krokodil abuse, one of the most dangerous and homemade psychoactive illicit substances, should be considered.

CONCLUSIONS

Further research into the etiology and site specificity of MRONJ is encouraged, aiming to develop novel treatment prospects. Indeed, comprehending this would allow for increased efficacy and therapeutic options while emphasizing the importance of prevention. In addition, we advocate for greater consensus among the various societies regarding MRONJ's treatment and management.

EthoLeciplex: A new tool for effective cutaneous delivery of minoxidil

This work designates EthoLeciplex, a vesicular system consisting of phospholipid, CTAB, ethanol and water, as an innovative vesicular system for cutaneous/transfollicular minoxidil delivery. Minoxidil loaded EthoLeciplex was fabricated by one-step fabrication process. Formulations were designed to study the effects of drug/phospholipid ratio, CTAB/phospholipid ratio, and ethanol concentration on vesicular size, PDI, surface charge and EE%. The optimized formulation was characterized by in vitro release, drug/excipient compatibility, ex vivo skin permeability and safety. A size of 83.6 ± 7.3 to 530.3 ± 29.4 nm, PDI of 0.214 ± 0.01 to 0.542 ± 0.08, and zeta potential of +31.6 ± 4.8 to +57.4 ± 12.5 mV were observed. Encapsulation efficiency was obtained in its maximum value (91.9 ± 16.2%) at the lowest drug/phospholipid ratio, median CTAB/phospholipid and the highest ethanol concentration. The optimized formulation was consisted of 0.3 as drug/lipid ratio, 1.25 as CTAB/lipid ratio and 30% ethanol concentration and showed responses' values in agreement with the predicted results. DSC studies suggested that EthoLeciplex existed in flexible state with complete incorporation of minoxidil into lipid bilayer. The cumulative amount of minoxidil permeated from EthoLeciplex, conventional liposome and ethanolic solution after 12h were 36.3 ± 1.5 µg/ml, 21 ± 2.0 µg/ml and 55 ± 4.0 µg/ml respectively. Based on the remaining amount, the amount of minoxidil accumulated in different skin layers can be predicted in descending order as follows; EthoLeciplex > conventional liposome > minoxidil solution. EthoLeciplex produced marked disorder in the stratum corneum integrity and swelling with no features of skin toxicity. This new cationic system is a promising carrier for cutaneous/transfollicular drug delivery.

Toxic desomorphine encephalopathy due to the use of “Krokodil”: clinical and neuroimaging features

Background: Toxic desomorphine encephalopathy (TDE) is a pathological condition that develops as a result of the intravenous use of a drug called Krokodil containing desomorphine, made in the artisanal conditions using codeine-containing drugs, organic solvents (gasoline), iodine and red phosphorus. This disease is more often observed in the CIS countries. In addition to the acute and chronic pathological conditions with the damage to various organs, the use of Krokodil is characterized by pronounced extrapyramidal manifestations in the form of dystonia, parkinsonism, postural disorders, as well as the occurrence of cognitive and affective disorders. Aims: To find the clinical and neuroimaging features of toxic desomorphine encephalopathy, as well as possible methods of its treatment. Methods: A clinical analysis of the medical documentation of 21 TDE patients (11 women and 10 men) with a history of the use of Krokodil was carried out, the patients had been under observation from 2014 to 2021. All the patients underwent a clinical physical and neurological examination, 14 of them underwent neuroimaging (brain MRI and/or MSCT). The observation of these patients revealed a number of characteristic clinical and neuroimaging features inherent in the majority of drug addicts. Results: The clinical picture of patients with TDE was dominated by movement disorders. All the patients had pronounced postural disorders and gait disturbance. Parkinsonism was observed in 20 of 21 patients. The hyperkinetic syndrome was presented in 17 patients (80.9%) and was manifested by dystonia of various localization with polymorphic manifestations. The brain MRI data taken from the Krokodil users for 3 years were characterized by symmetrical focal changes in the basal ganglia, brainstem, cerebellum and internal capsule of the thalamus in the form of an increase in the intensity of the MR signal in the T1 mode and attenuation in the T2-weighted images mode (7 of 11 cases), with the subsequent regression of these characteristics based on the results of the subsequent MRI studies. Conclusion: The study results have revealed the clinical manifestations characteristic of TDE polymorphic extrapyramidal disorders, as well as neuroimaging changes reflecting these data.

DARK Classics in Chemical Neuroscience: Krokodil

Krokodil is the street name for a homemade mixture that has been used as a cheap substitute for heroin. The main active substance in krokodil is desomorphine, an opioid that is 10 times more potent than morphine. Krokodil use began in Russia and Ukraine but has spread throughout several countries in Europe and North America. Krokodil is produced from codeine tablets in a bootleg reaction performed under clandestine and unsanitary conditions. The toxicity of krokodil is characterized by devastating symptoms that start as black ulcers at the injection site and evolve to gangrene and limb amputation. The dangerous effects of krokodil are associated with its homemade nature and lack of purification prior to use. In this review, we discuss the chemical and pharmacological properties and the metabolism of desomorphine, the preparation of krokodil, and how its homemade nature contributes to its toxicity. The synthesis of krokodil produces several other morphinans in addition to desomorphine that warrant further study as possible analgesic alternatives to morphine.

DARK Classics in Chemical Neuroscience: Heroin and Desomorphine

Opioids are arguably one of the most important pharmacologic classes, mainly due to their rich history, their useful and potent analgesic effects, and also, just as importantly, their "Dark Side", constituted by their reinforcing properties that have led countless of users to a spiral of addiction, biological dependence, tolerance, withdrawal syndromes, and death. Among the most significant abused and addictive known opioids are heroin and desomorphine, both synthetic derivatives of morphine that belong to the 4,5-epoxymorphinan structural chemical group of the opioid family drugs. These agents share not only structural, pharmacological, and epidemiological features but also a common geographical distribution. A drop in Afghan heroin production and its "exports" to Russia gave rise to widespread consumption of desomorphine in ex-Soviet republics during the first decade of the 21st century, representing an economical and accessible alternative for misusers to this sort of derivative. Herein we review the state of the art of history, chemistry and synthesis, pharmacology, and impact on society of these "cursed cousins".

Speckle-tracking strain assessment of left ventricular dysfunction in synthetic cannabinoid and heroin users

Objective

There is growing evidence regarding the numerous adverse effects of synthetic cannabinoids (SCBs) on the cardiovascular system; however, no studies have shown the cardiovascular effects of opioids using strain echocardiography. This study examines the cardiac structure and function using echocardiographic strain imaging in heroin and synthetic cannabinoid users.

Methods

This double-blind study included patients who were admitted or referred to a rehabilitation center for heroin (n=31) and synthetic cannabinoid users (n=30). Heroin users and synthetic cannabinoid users were compared with healthy volunteers (n=32) using two-dimensional (2D) speckle-tracking (ST) echocardiography.

Results

No differences were found in the baseline characteristics and 2D echocardiography values. The mean global longitudinal strain value was −20.5%±2.4% for SCB users, −22.3%±2.4% for opioid users, and −22.5%±2.2% for healthy volunteers (p=0.024). The mean apical 2-chamber (AP2C) L-strain values were −20.1%±3.1%, −22.4%±3.0%, and −22.3%±2.8% for SCB users, opioid users, and healthy volunteers, respectively (p=0.032). The mean apical 4-chamber (AP4C) L-strain values were −20.7%±2.5% for SCB users, −23.2%±3.2% for opioid users, and −23.8%±3.1% for healthy volunteers (p<0.001).

Conclusion

SCBs are potential causes of subclinical left ventricular dysfunction.