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Brooks-Russell A, Wrobel J, Brown T, Bidwell LC, Wang GS, Steinhart B, Dooley G, Kosnett MJ. Effects of acute cannabis inhalation on reaction time, decision-making, and memory using a tablet-based application. J Cannabis Res 2024; 6:3. [PMID: 38308382 PMCID: PMC10837858 DOI: 10.1186/s42238-024-00215-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 01/13/2024] [Indexed: 02/04/2024] Open
Abstract
BACKGROUND Acute cannabis use has been demonstrated to slow reaction time and affect decision-making and short-term memory. These effects may have utility in identifying impairment associated with recent use. However, these effects have not been widely investigated among individuals with a pattern of daily use, who may have acquired tolerance. The purpose of this study was to examine the impact of tolerance to cannabis on the acute effects as measured by reaction time, decision-making (gap acceptance), and short-term memory. METHODS Participants (ages 25-45) completed a tablet-based (iPad) test battery before and approximately 60 min after smoking cannabis flower. The change in performance from before to after cannabis use was compared across three groups of cannabis users: (1) occasional use (n = 23); (2) daily use (n = 31); or (3) no current use (n = 32). Participants in the occasional and daily use group self-administered ad libitum, by smoking or vaping, self-supplied cannabis flower with a high concentration of total THC (15-30%). RESULTS The occasional use group exhibited decrements in reaction time (slowed) and short-term memory (replicated fewer shapes) from before to after cannabis use, as compared to the no-use group. In the gap acceptance task, daily use participants took more time to complete the task post-smoking cannabis as compared to those with no use or occasional use; however, the level of accuracy did not significantly change. CONCLUSIONS The findings are consistent with acquired tolerance to certain acute psychomotor effects with daily cannabis use. The finding from the gap acceptance task which showed a decline in speed but not accuracy may indicate a prioritization of accuracy over response time. Cognitive and psychomotor assessments may have utility for identifying impairment associated with recent cannabis use.
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Affiliation(s)
- Ashley Brooks-Russell
- Injury and Violence Prevention Center, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, 13001 E. 17Th Place, Aurora, CO, 80045, USA.
| | - Julia Wrobel
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Tim Brown
- Driving Safety Research Institute, University of Iowa, Iowa City, IA, USA
| | - L Cinnamon Bidwell
- Institute of Cognitive Science, University of Colorado, Boulder, CO, USA
| | - George Sam Wang
- Department of Pediatrics, CU School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Benjamin Steinhart
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Gregory Dooley
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO, USA
| | - Michael J Kosnett
- Department of Medicine, CU School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Department of Environmental and Occupational Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Wang GS, Kosnett M, Subramanian P, Wrobel J, Ma M, Brown T, Bidwell LC, Brooks-Russell A. Accuracy and replicability of identifying eyelid tremor as an indicator of recent cannabis smoking. Clin Toxicol (Phila) 2024; 62:10-18. [PMID: 38421358 PMCID: PMC11019859 DOI: 10.1080/15563650.2024.2310154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 01/19/2024] [Indexed: 03/02/2024]
Abstract
INTRODUCTION Cannabis intoxication may increase the risk of motor vehicle crashes. However, reliable methods of assessing cannabis intoxication are limited. The presence of eyelid tremors is among the signs of cannabis use identified under the Drug Evaluation and Classification Program of the International Association of Chiefs of Police. Our objectives were to assess the accuracy and replicability of identifying eyelid tremor as an indicator of recent cannabis smoking using a blinded, controlled study design. METHODS Adult subjects (N = 103) were recruited into three groups based on their cannabis use history: daily, occasional, and no current cannabis use. Participants' closed eyelids were video recorded for 30 seconds by infrared videography goggles before and at a mean ± standard deviation time of 71.4 ± 4.6 minutes after the onset of a 15-minute interval of ad libitum cannabis flower smoking or vaping. Three observers with expertise in neuro-ophthalmology and medical toxicology were trained on exemplar videos of eyelids to reach a consensus on how to grade eyelid tremor. Without knowledge of subjects' cannabis use history or time point (pre- or post-smoking), observers reviewed each video for eyelid tremor graded as absent, slight, moderate, or severe. During subsequent data analysis, this score was further dichotomized as a consensus score of absent (absent/slight) or present (moderate/severe). RESULTS Kappa and intraclass correlation coefficient statistics demonstrated moderate agreement among the coders, which ranged from 0.44-0.45 and 0.58-0.61, respectively. There was no significant association between recent cannabis use and the observers' consensus assessment that eyelid tremor was present, and cannabis users were less likely to have tremors (odds ratio: 0.75; 95 percent confidence interval: 0.25, 2.40). The assessment of eyelid tremor as an indicator of recent cannabis smoking had a sensitivity of 0.86, specificity of 0.18, and accuracy of 0.64. DISCUSSION Eyelid tremor has fair sensitivity but poor specificity and accuracy for identification of recent cannabis use. Inter-rater reliability for assessment of eyelid tremor was moderate for the presence and degree of tremor. The weak association between recent cannabis use and eyelid tremor does not support its utility in identifying recent cannabis use. LIMITATIONS Videos were recorded at only one time point after cannabis use. Adherence to abstinence could not be strictly supervised. Due to regulatory restrictions, we were unable to control the cannabis product used or administer a fixed Δ9-tetrahydrocannabinol dose. Participants were predominately non-Hispanic and White. CONCLUSIONS In a cohort of participants with a range of cannabis use histories, acute cannabis smoking was not associated with the presence of eyelid tremor, regardless of cannabis use history, at 70 minutes post-smoking. Additional research is needed to identify the presence of eyelid tremor accurately, determine the relationship between cannabis dose and timeline in relation to last cannabis use to eyelid tremor, and determine how it should be, if at all, utilized for cannabis Drug Recognition Evaluator examinations.
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Affiliation(s)
- George Sam Wang
- University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO, USA
| | - Michael Kosnett
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Prem Subramanian
- Departments of Ophthalmology, Neurology, and Neurosurgery, Sue Anschutz-Rodgers University of Colorado Eye Center, Aurora, CO, USA
| | - Julia Wrobel
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, GA, USA
| | - Ming Ma
- Department of Biostatistics, Medpace, Denver, CO, USA
| | - Tim Brown
- Driving Safety Research Institute, College of Engineering, University of Iowa, Iowa City, Iowa, USA
| | - L Cinnamon Bidwell
- Institute of Cognitive Science, University of Colorado Boulder, Boulder, CO, USA
| | - Ashley Brooks-Russell
- Injury and Violence Prevention Center, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Bero L, Lawrence R, Oberste JP, Li T, Leslie L, Rittiphairoj T, Piper C, Wang GS, Brooks-Russell A, Yim TW, Tung G, Samet JM. Health Effects of High-Concentration Cannabis Products: Scoping Review and Evidence Map. Am J Public Health 2023; 113:1332-1342. [PMID: 37939329 PMCID: PMC10632847 DOI: 10.2105/ajph.2023.307414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2023] [Indexed: 11/10/2023]
Abstract
Background. The concentration of pharmacologically active tetrahydrocannabinol (THC) in cannabis products has been increasing over the past decade. Concerns about potential harmful health effects of using these increasingly higher-concentration products have led some states to consider regulation of cannabis product THC concentration. We conducted a scoping review of health effects of high-concentration cannabis products to inform policy on whether the THC concentrations of cannabis product should be regulated or limited. Objectives. We conducted a scoping review to (1) identify and describe human studies that explore the relationship of high-concentration cannabis products with any health outcomes in the literature and (2) create an interactive evidence map of the included studies to facilitate further analyses. Search Methods. An experienced medical information specialist designed a comprehensive search strategy of 7 electronic databases. Selection Criteria. We included human studies of any epidemiological design with no restrictions by age, sex, health status, country, or outcome measured that reported THC concentration or included a known high-concentration cannabis product. Data Collection and Analysis. We imported search results into Distiller SR, and trained coders conducted artificial intelligence‒assisted screening. We developed, piloted, and revised data abstraction forms. One person performed data abstraction, and a senior reviewer verified a subset. We provide a tabular description of study characteristics, including exposures and outcomes measured, for each included study. We interrogated the evidence map published in Tableau to answer specific questions and provide the results as text and visual displays. Main Results. We included 452 studies in the scoping review and evidence map. There was incomplete reporting of exposure characteristics including THC concentration, duration and frequency of use, and products used. The evidence map shows considerable heterogeneity among studies in exposures, outcomes, and populations studied. A limited number of reports provided data that would facilitate further quantitative synthesis of the results across studies. Conclusions. This scoping review and evidence map support strong conclusions concerning the utility of the literature for characterizing risks and benefits of the current cannabis marketplace and the research approaches followed in the studies identified. Relevance of the studies to today's products is limited. Public Health Implications. High-quality evidence to address the policy question of whether the THC concentration of cannabis products should be regulated is scarce. The publicly available interactive evidence map is a timely resource for other entities concerned with burgeoning access to high-concentration cannabis. (Am J Public Health. 2023;113(12):1332-1342. https://doi.org/10.2105/AJPH.2023.307414).
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Affiliation(s)
- Lisa Bero
- Lisa Bero and Rosa Lawrence are with the Department of General Internal Medicine, Center for Bioethics and Humanities, University of Colorado, Anschutz Medical Campus, Aurora. Jean-Pierre Oberste, Tianjing Li, Louis Leslie, and Tsz Wing Yim are with Department of Ophthalmology, University of Colorado, Anschutz Medical Campus. Thanitsara Rittiphairoj is with Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. Christi Piper is with Strauss Health Sciences Library, University of Colorado, Anschutz Medical Campus. George Sam Wang is with Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Anschutz Medical Campus. Ashley Brooks-Russell is with Department of Community and Behavioral Health, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus. Gregory Tung is with Department of Epidemiology, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus. Jonathan M. Samet is with Office of the Dean, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus
| | - Rosa Lawrence
- Lisa Bero and Rosa Lawrence are with the Department of General Internal Medicine, Center for Bioethics and Humanities, University of Colorado, Anschutz Medical Campus, Aurora. Jean-Pierre Oberste, Tianjing Li, Louis Leslie, and Tsz Wing Yim are with Department of Ophthalmology, University of Colorado, Anschutz Medical Campus. Thanitsara Rittiphairoj is with Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. Christi Piper is with Strauss Health Sciences Library, University of Colorado, Anschutz Medical Campus. George Sam Wang is with Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Anschutz Medical Campus. Ashley Brooks-Russell is with Department of Community and Behavioral Health, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus. Gregory Tung is with Department of Epidemiology, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus. Jonathan M. Samet is with Office of the Dean, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus
| | - Jean-Pierre Oberste
- Lisa Bero and Rosa Lawrence are with the Department of General Internal Medicine, Center for Bioethics and Humanities, University of Colorado, Anschutz Medical Campus, Aurora. Jean-Pierre Oberste, Tianjing Li, Louis Leslie, and Tsz Wing Yim are with Department of Ophthalmology, University of Colorado, Anschutz Medical Campus. Thanitsara Rittiphairoj is with Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. Christi Piper is with Strauss Health Sciences Library, University of Colorado, Anschutz Medical Campus. George Sam Wang is with Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Anschutz Medical Campus. Ashley Brooks-Russell is with Department of Community and Behavioral Health, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus. Gregory Tung is with Department of Epidemiology, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus. Jonathan M. Samet is with Office of the Dean, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus
| | - Tianjing Li
- Lisa Bero and Rosa Lawrence are with the Department of General Internal Medicine, Center for Bioethics and Humanities, University of Colorado, Anschutz Medical Campus, Aurora. Jean-Pierre Oberste, Tianjing Li, Louis Leslie, and Tsz Wing Yim are with Department of Ophthalmology, University of Colorado, Anschutz Medical Campus. Thanitsara Rittiphairoj is with Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. Christi Piper is with Strauss Health Sciences Library, University of Colorado, Anschutz Medical Campus. George Sam Wang is with Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Anschutz Medical Campus. Ashley Brooks-Russell is with Department of Community and Behavioral Health, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus. Gregory Tung is with Department of Epidemiology, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus. Jonathan M. Samet is with Office of the Dean, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus
| | - Louis Leslie
- Lisa Bero and Rosa Lawrence are with the Department of General Internal Medicine, Center for Bioethics and Humanities, University of Colorado, Anschutz Medical Campus, Aurora. Jean-Pierre Oberste, Tianjing Li, Louis Leslie, and Tsz Wing Yim are with Department of Ophthalmology, University of Colorado, Anschutz Medical Campus. Thanitsara Rittiphairoj is with Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. Christi Piper is with Strauss Health Sciences Library, University of Colorado, Anschutz Medical Campus. George Sam Wang is with Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Anschutz Medical Campus. Ashley Brooks-Russell is with Department of Community and Behavioral Health, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus. Gregory Tung is with Department of Epidemiology, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus. Jonathan M. Samet is with Office of the Dean, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus
| | - Thanitsara Rittiphairoj
- Lisa Bero and Rosa Lawrence are with the Department of General Internal Medicine, Center for Bioethics and Humanities, University of Colorado, Anschutz Medical Campus, Aurora. Jean-Pierre Oberste, Tianjing Li, Louis Leslie, and Tsz Wing Yim are with Department of Ophthalmology, University of Colorado, Anschutz Medical Campus. Thanitsara Rittiphairoj is with Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. Christi Piper is with Strauss Health Sciences Library, University of Colorado, Anschutz Medical Campus. George Sam Wang is with Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Anschutz Medical Campus. Ashley Brooks-Russell is with Department of Community and Behavioral Health, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus. Gregory Tung is with Department of Epidemiology, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus. Jonathan M. Samet is with Office of the Dean, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus
| | - Christi Piper
- Lisa Bero and Rosa Lawrence are with the Department of General Internal Medicine, Center for Bioethics and Humanities, University of Colorado, Anschutz Medical Campus, Aurora. Jean-Pierre Oberste, Tianjing Li, Louis Leslie, and Tsz Wing Yim are with Department of Ophthalmology, University of Colorado, Anschutz Medical Campus. Thanitsara Rittiphairoj is with Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. Christi Piper is with Strauss Health Sciences Library, University of Colorado, Anschutz Medical Campus. George Sam Wang is with Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Anschutz Medical Campus. Ashley Brooks-Russell is with Department of Community and Behavioral Health, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus. Gregory Tung is with Department of Epidemiology, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus. Jonathan M. Samet is with Office of the Dean, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus
| | - George Sam Wang
- Lisa Bero and Rosa Lawrence are with the Department of General Internal Medicine, Center for Bioethics and Humanities, University of Colorado, Anschutz Medical Campus, Aurora. Jean-Pierre Oberste, Tianjing Li, Louis Leslie, and Tsz Wing Yim are with Department of Ophthalmology, University of Colorado, Anschutz Medical Campus. Thanitsara Rittiphairoj is with Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. Christi Piper is with Strauss Health Sciences Library, University of Colorado, Anschutz Medical Campus. George Sam Wang is with Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Anschutz Medical Campus. Ashley Brooks-Russell is with Department of Community and Behavioral Health, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus. Gregory Tung is with Department of Epidemiology, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus. Jonathan M. Samet is with Office of the Dean, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus
| | - Ashley Brooks-Russell
- Lisa Bero and Rosa Lawrence are with the Department of General Internal Medicine, Center for Bioethics and Humanities, University of Colorado, Anschutz Medical Campus, Aurora. Jean-Pierre Oberste, Tianjing Li, Louis Leslie, and Tsz Wing Yim are with Department of Ophthalmology, University of Colorado, Anschutz Medical Campus. Thanitsara Rittiphairoj is with Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. Christi Piper is with Strauss Health Sciences Library, University of Colorado, Anschutz Medical Campus. George Sam Wang is with Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Anschutz Medical Campus. Ashley Brooks-Russell is with Department of Community and Behavioral Health, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus. Gregory Tung is with Department of Epidemiology, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus. Jonathan M. Samet is with Office of the Dean, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus
| | - Tsz Wing Yim
- Lisa Bero and Rosa Lawrence are with the Department of General Internal Medicine, Center for Bioethics and Humanities, University of Colorado, Anschutz Medical Campus, Aurora. Jean-Pierre Oberste, Tianjing Li, Louis Leslie, and Tsz Wing Yim are with Department of Ophthalmology, University of Colorado, Anschutz Medical Campus. Thanitsara Rittiphairoj is with Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. Christi Piper is with Strauss Health Sciences Library, University of Colorado, Anschutz Medical Campus. George Sam Wang is with Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Anschutz Medical Campus. Ashley Brooks-Russell is with Department of Community and Behavioral Health, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus. Gregory Tung is with Department of Epidemiology, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus. Jonathan M. Samet is with Office of the Dean, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus
| | - Gregory Tung
- Lisa Bero and Rosa Lawrence are with the Department of General Internal Medicine, Center for Bioethics and Humanities, University of Colorado, Anschutz Medical Campus, Aurora. Jean-Pierre Oberste, Tianjing Li, Louis Leslie, and Tsz Wing Yim are with Department of Ophthalmology, University of Colorado, Anschutz Medical Campus. Thanitsara Rittiphairoj is with Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. Christi Piper is with Strauss Health Sciences Library, University of Colorado, Anschutz Medical Campus. George Sam Wang is with Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Anschutz Medical Campus. Ashley Brooks-Russell is with Department of Community and Behavioral Health, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus. Gregory Tung is with Department of Epidemiology, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus. Jonathan M. Samet is with Office of the Dean, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus
| | - Jonathan M Samet
- Lisa Bero and Rosa Lawrence are with the Department of General Internal Medicine, Center for Bioethics and Humanities, University of Colorado, Anschutz Medical Campus, Aurora. Jean-Pierre Oberste, Tianjing Li, Louis Leslie, and Tsz Wing Yim are with Department of Ophthalmology, University of Colorado, Anschutz Medical Campus. Thanitsara Rittiphairoj is with Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. Christi Piper is with Strauss Health Sciences Library, University of Colorado, Anschutz Medical Campus. George Sam Wang is with Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Anschutz Medical Campus. Ashley Brooks-Russell is with Department of Community and Behavioral Health, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus. Gregory Tung is with Department of Epidemiology, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus. Jonathan M. Samet is with Office of the Dean, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus
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Lavonas EJ, Akpunonu PD, Arens AM, Babu KM, Cao D, Hoffman RS, Hoyte CO, Mazer-Amirshahi ME, Stolbach A, St-Onge M, Thompson TM, Wang GS, Hoover AV, Drennan IR. 2023 American Heart Association Focused Update on the Management of Patients With Cardiac Arrest or Life-Threatening Toxicity Due to Poisoning: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2023; 148:e149-e184. [PMID: 37721023 DOI: 10.1161/cir.0000000000001161] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
In this focused update, the American Heart Association provides updated guidance for resuscitation of patients with cardiac arrest, respiratory arrest, and refractory shock due to poisoning. Based on structured evidence reviews, guidelines are provided for the treatment of critical poisoning from benzodiazepines, β-adrenergic receptor antagonists (also known as β-blockers), L-type calcium channel antagonists (commonly called calcium channel blockers), cocaine, cyanide, digoxin and related cardiac glycosides, local anesthetics, methemoglobinemia, opioids, organophosphates and carbamates, sodium channel antagonists (also called sodium channel blockers), and sympathomimetics. Recommendations are also provided for the use of venoarterial extracorporeal membrane oxygenation. These guidelines discuss the role of atropine, benzodiazepines, calcium, digoxin-specific immune antibody fragments, electrical pacing, flumazenil, glucagon, hemodialysis, hydroxocobalamin, hyperbaric oxygen, insulin, intravenous lipid emulsion, lidocaine, methylene blue, naloxone, pralidoxime, sodium bicarbonate, sodium nitrite, sodium thiosulfate, vasodilators, and vasopressors for the management of specific critical poisonings.
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Buttorff C, Wang GS, Wilks A, Tung G, Kress A, Schwam D, Pacula RL. Impact of Recreational Cannabis Legalization on Opioid Prescribing and Opioid-Related Hospital Visits in Colorado: an Observational Study. J Gen Intern Med 2023; 38:2726-2733. [PMID: 37340250 PMCID: PMC10506996 DOI: 10.1007/s11606-023-08195-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 03/30/2023] [Indexed: 06/22/2023]
Abstract
BACKGROUND Cannabis may be a substitute for opioids but previous studies have found conflicting results when using data from more recent years. Most studies have examined the relationship using state-level data, missing important sub-state variation in cannabis access. OBJECTIVE To examine cannabis legalization on opioid use at the county level, using Colorado as a case study. Colorado allowed recreational cannabis stores in January 2014. Local communities could decide whether to allow dispensaries, creating variation in the level of exposure to cannabis outlets. DESIGN Observational, quasi-experimental design exploiting county-level variation in allowance of recreational dispensaries. SUBJECTS Colorado residents MEASURES: We use licensing information from the Colorado Department of Revenue to measure county-level exposure to cannabis outlets. We use the state's Prescription Drug Monitoring Program (2013-2018) to construct opioid-prescribing measures of number of 30-day fills and total morphine equivalents, both per county resident per quarter. We construct outcomes of opioid-related inpatient visits (2011-2018) and emergency department visits (2013-2018) with Colorado Hospital Association data. We use linear models in a differences-in-differences framework that accounts for the varying exposure to medical and recreational cannabis over time. There are 2048 county-quarter observations used in the analysis. RESULTS We find mixed evidence of cannabis exposure on opioid-related outcomes at the county level. We find increasing exposure to recreational cannabis is associated with a statistically significant decrease in number of 30-day fills (coefficient: -117.6, p-value<0.01) and inpatient visits (coefficient: -0.8, p-value: 0.03), but not total MME nor ED visits. Counties with no medical exposure prior to recreational legalization experience greater reductions in the number of 30-day fills and MME than counties with prior medical exposure (p=0.02 for both). CONCLUSIONS Our mixed findings suggest that further increases in cannabis beyond medical access may not always reduce opioid prescribing or opioid-related hospital visits at a population level.
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Affiliation(s)
| | - George Sam Wang
- Department of Pediatrics, Children’s Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO USA
| | - Asa Wilks
- RAND Corporation, Santa Monica, CA USA
| | - Gregory Tung
- Department of Health Systems, Management & Policy, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO USA
| | - Amii Kress
- ECHO Data Analysis Center, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | | | - Rosalie Liccardo Pacula
- Sol Price School of Public Policy, Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles, CA USA
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Liu N, Meng QX, Wang GS. [The relationship between the expression of amplified in breast cancer 1、androgen receptor and tamoxifen resistance in breast cancer]. Zhonghua Yi Xue Za Zhi 2023; 103:1553-1559. [PMID: 37246005 DOI: 10.3760/cma.j.cn112137-20230115-00081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Objective: To discuss the value of amplified in breast cancer 1(AIB1) and androgen receptor (AR) for the resistance of adjuvant tamoxifen in estradiol receptor (ER) positive breast cancer. Methods: A total of 188 cases with breast cancer after receiving tamoxifen treatment in the Tianjin Medical University Cancer Institute and Hospital from June 2008 to July 2013 were enrolled in this study.Using immunohistochemical SP method to detect AIB1and AR expression in breast cancer tissue, analyzing the relationship of AIB1 and AR expression and the effect of tamoxifen.And verify the results of the experiment through the GEPIA database. Results: The response of tamoxifen was 80.3%. The response rate in AR positive group and AR negative group was 79.6% and 82.4%, with no significant difference (P=0.669). The response rate in AIB1 High expression group and AIB1 Low expression group was 68.4% and 93.3%, respectively, with a significant difference (P<0.001).The response rate in AR negative and AIB1 Low expression group, AR negative and AIB1 High expression group, AR positive and AIB1 Low expression group, AR positive and AIB1High expression group was 89.7%, 71.4%, 96.7%, 66.2%respectively, with a significant difference (P<0.001). Conclusions: The expression level of AIB1 is correlated with the therapeutic effect of tamoxifen in breast cancer. Its high expression can cause tamoxifen resistance, while AR positive and High expression of AIB1 are more likely to cause tamoxifen resistance, and AIB1 can be used as an independent influencing factor for breast cancer tamoxifentreatment.
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Affiliation(s)
- N Liu
- Department of Pathology, Tianjin Baodi Hospital, Tianjin 301800, China
| | - Q X Meng
- Department of Anesthesiology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research for Cancer, Tianjin 300060, China
| | - G S Wang
- Department of Oncology, Tianjin Baodi Hospital, Tianjin 301800, China
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Kosnett MJ, Ma M, Dooley G, Wang GS, Friedman K, Brown T, Henthorn TK, Brooks-Russell A. Blood cannabinoid molar metabolite ratios are superior to blood THC as an indicator of recent cannabis smoking. Clin Toxicol (Phila) 2023; 61:355-362. [PMID: 37293900 PMCID: PMC10481452 DOI: 10.1080/15563650.2023.2214697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 04/28/2023] [Accepted: 05/05/2023] [Indexed: 06/10/2023]
Abstract
INTRODUCTION Cannabis use is a growing concern in transportation and workplace incidents. Because Δ9-tetrahydrocannabinol is detectable after acute psychoactive effects have resolved, it has limitations as an indicator of recent usage or potential impairment. METHODS In an observational study of driving and psychomotor performance, we measured whole blood Δ9-tetrahydrocannabinol plus its metabolites 11-hydroxy-Δ9-tetrahydrocannabinol and 11-nor-9-carboxy-Δ9-tetrahydrocannabinol by liquid chromatography with tandem mass spectrometry at baseline and 30 min after starting a 15-minute interval of smoking cannabis in 24 occasional and 32 daily cannabis smokers. We calculated two blood cannabinoid molar metabolite ratios: 1) [Δ9-tetrahydrocannabinol] to [11-nor-9-carboxy-Δ9-tetrahydrocannabinol] and 2) ([Δ9-tetrahydrocannabinol] + [11-hydroxy-Δ9-tetrahydrocannabinol]) to [11-nor-9-carboxy-Δ9-tetrahydrocannabinol]. We compared these to blood [Δ9-tetrahydrocannabinol] alone as indicators of recent cannabis smoking. RESULTS Median Δ9-tetrahydrocannabinol concentrations increased from 0 ( 0.38). By comparison, a cut-point for Δ9-tetrahydrocannabinol of 5.3 µg/L yielded 88% specificity, 73% sensitivity, and 80% accuracy. CONCLUSIONS In occasional and daily users, the blood cannabinoid molar metabolite ratios were superior to whole blood Δ9-tetrahydrocannabinol as indicators of recent cannabis smoking. We recommend measurement and reporting of Δ9-tetrahydrocannabinol, 11-hydroxy-Δ9-tetrahydrocannabinol, and 11-nor-9-carboxy-Δ9-tetrahydrocannabinol, and their molar metabolite ratios in forensic and safety investigations.
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Affiliation(s)
- Michael J. Kosnett
- Department of Environmental and Occupational Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
- Department of Medicine, University of Colorado School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Ming Ma
- Department of Community and Behavioral Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Gregory Dooley
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO, United States
| | - George Sam Wang
- Department of Pediatrics, University of Colorado School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Kyle Friedman
- Rocky Mountain Poison and Drug Safety, Denver Health, Denver, CO, United States
| | - Timothy Brown
- Driving Safety Research Institute, University of Iowa, Iowa City, IA, United States
| | - Thomas K. Henthorn
- Department of Anesthesiology and Pharmaceutical Sciences, University of Colorado School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO United States
| | - Ashley Brooks-Russell
- Department of Community and Behavioral Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
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Rague JM, Ma M, Dooley G, Sam Wang G, Friedman K, Henthorn TK, Brooks-Russell A, Kosnett MJ. The minor cannabinoid cannabigerol (CBG) is a highly specific blood biomarker of recent cannabis smoking. Clin Toxicol (Phila) 2023; 61:363-369. [PMID: 36939145 PMCID: PMC10428941 DOI: 10.1080/15563650.2023.2173076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 01/02/2023] [Accepted: 01/22/2023] [Indexed: 03/21/2023]
Abstract
INTRODUCTION The determination of recent cannabis use is of forensic interest in the investigation of automotive crashes, workplace incidents and other mishaps. Because Δ9-tetrahydrocannabinol may persist in blood after psychoactive effects of intoxication resolve, particularly in regular users, short-lived minor cannabinoids such as cannabigerol have merited examination as adjunct indicators of recent cannabis inhalation. METHODS As part of an observational cohort study, whole blood cannabinoids including cannabigerol were measured in whole blood by liquid chromatography with tandem mass spectrometry at baseline, and 30 minutes after initiation of a 15-minute supervised interval of ad libitum cannabis smoking in occasional (1-2 days/week over the past 30 days) (n = 24) and daily cannabis smokers (n = 32). Per protocol, subjects self-reported abstention from inhaling cannabis (>8 h) or ingesting cannabis (>12 h) prior to baseline measurement. RESULTS At baseline, none of the occasional users had detectable cannabigerol (limit of detection = 0.2 µg/L), whereas cannabigerol was detectable post-smoking in 7 of 24 (29%). Among daily cannabis users, 2 of 32 (6%) had detectable cannabigerol at baseline, increasing to 21 of 32 (66%) post-smoking. The odds ratio for recent cannabis smoking associated with a detectable cannabigerol was 27 (95% confidence interval: 6.6, 110.3). In this mixed cohort of occasional and daily cannabis users, receiver operator characteristic curve analysis indicated that whole blood cannabigerol concentration of ≥ 0.2 µg/L had 96% specificity, 50% sensitivity, and 73% accuracy for identifying a 15-minute interval of ad libitum cannabis smoking initiated 30 minutes earlier. Post smoking blood Δ9-tetrahydrocannabinol (median = 5.6 µg/L in occasional users, 21.3 µg/L in daily users) was significantly correlated with post-smoking cannabigerol (P < 0.0001). CONCLUSION Whole blood cannabigerol may have forensic utility as a highly specific albeit insensitive biomarker of recent cannabis smoking.
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Affiliation(s)
- John M. Rague
- Rocky Mountain Poison and Drug Safety, Denver Health, Denver, CO, United States
| | - Ming Ma
- Department of Community and Behavioral Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Gregory Dooley
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO, United States
| | - George Sam Wang
- Department of Pediatrics, University of Colorado School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Kyle Friedman
- Rocky Mountain Poison and Drug Safety, Denver Health, Denver, CO, United States
| | - Thomas K. Henthorn
- Department of Anesthesiology and Pharmaceutical Sciences, University of Colorado School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO United States
| | - Ashley Brooks-Russell
- Department of Community and Behavioral Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Michael J. Kosnett
- Department of Environmental and Occupational Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
- Department of Medicine, University of Colorado School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
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9
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Zhang GY, Cao Y, Feng ZF, Wang GS, Li ZR. [Effect of jejunal feeding tube placement on complications after laparoscopic radical surgery in patients with incomplete pyloric obstruction by gastric antrum cancer]. Zhonghua Wei Chang Wai Ke Za Zhi 2023; 26:175-180. [PMID: 36797564 DOI: 10.3760/cma.j.cn441530-20220928-00395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
Objective: To assess the effect of jejunal feeding tube placement on early complications of laparoscopic radical gastrectomy in patients with incomplete pyloric obstruction by gastric cancer. Methods: This was a retrospective cohort study. Perioperative clinical data of 151 patients with gastric antrum cancer complicated by incomplete pyloric obstruction who had undergone laparoscopic distal radical gastrectomy from May 2020 to May 2022 in the First Affiliated Hospital of Nanchang University were collected. Intraoperative jejunal feeding tubes had been inserted in 69 patients (nutrition tube group) and not in the remaining 82 patients (conventional group). There were no statistically significant differences in baseline characteristics between the two groups (all P>0.05). The operating time, intraoperative bleeding, time to first intake of solid food, time to passing first flatus, time to drainage tube removal, and postoperative hospital stay, and early postoperative complications (occurded within 30 days after surgery) were compared between the two groups. Results: Patients in both groups completed the surgery successfully and there were no deaths in the perioperative period. The operative time was longer in the nutritional tube group than in the conventional group [(209.2±4.7) minutes vs. (188.5±5.7) minutes, t=2.737, P=0.007], whereas the time to first postoperative intake of food [(2.7±0.1) days vs. (4.1±0.4) days, t=3.535, P<0.001], time to passing first flatus [(2.3±0.1) days vs. (2.8±0.1) days, t=3.999, P<0.001], time to drainage tube removal [(6.3±0.2) days vs. (6.9±0.2) days, t=2.123, P=0.035], and postoperative hospital stay [(7.8±0.2) days vs. (9.7±0.5) days, t=3.282, P=0.001] were shorter in the nutritional tube group than in the conventional group. There was no significant difference between the two groups in intraoperative bleeding [(101.1±9.0) mL vs. (111.4±8.7) mL, t=0.826, P=0.410]. The overall incidence of short-term postoperative complications was 16.6% (25/151). Postoperative complications did not differ significantly between the two groups (all P>0.05). Conclusion: It is safe and feasible to insert a jejunal feeding tube in patients with incomplete outlet obstruction by gastric antrum cancer during laparoscopic radical gastrectomy. Such tubes confer some advantages in postoperative recovery.
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Affiliation(s)
- G Y Zhang
- Department of digestive surgery,digestive disease hospital, the First Affiliated Hospital of Nanchang University; Department of general surgery, the First Affiliated Hospital of Nanchang University, Nanchang 330006, China
| | - Y Cao
- Department of digestive surgery,digestive disease hospital, the First Affiliated Hospital of Nanchang University; Department of general surgery, the First Affiliated Hospital of Nanchang University, Nanchang 330006, China
| | - Z F Feng
- Department of digestive surgery,digestive disease hospital, the First Affiliated Hospital of Nanchang University; Department of general surgery, the First Affiliated Hospital of Nanchang University, Nanchang 330006, China
| | - G S Wang
- Department of digestive surgery,digestive disease hospital, the First Affiliated Hospital of Nanchang University; Department of general surgery, the First Affiliated Hospital of Nanchang University, Nanchang 330006, China
| | - Z R Li
- Department of digestive surgery,digestive disease hospital, the First Affiliated Hospital of Nanchang University; Department of general surgery, the First Affiliated Hospital of Nanchang University, Nanchang 330006, China
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Xu WR, Wang GS, Li Q, Zheng JX, Guo ZY, Chen JX, Chen MX, Tian LG. [Epidemiological characteristics and influencing factors of Blastocystis hominis infection among children with diarrhea under five years of age in Guangzhou City]. Zhongguo Xue Xi Chong Bing Fang Zhi Za Zhi 2023; 34:598-603. [PMID: 36642899 DOI: 10.16250/j.32.1374.2022140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To investigate the prevalence and influencing factors of Blastocystis hominis infection among children with diarrhea under five years of age in Guangzhou City. METHODS Children with diarrhea under 5 years of age admitted to Guangzhou Children's hospital, Guangzhou Maternity and Child Healthcare Hospital and Guangzhou Women and Children's Medical Center during the period between January 1 and December 31, 2020, were enrolled. Participants' demographics, living environments and health status were collected using questionnaire surveys. Stool samples were collected from participants and nucleic acid was extracted. B. hominis infection was identified using PCR assay and sequence alignment, and the factors affecting B. hominis infection among children with diarrhea under 5 years of age were identified using univariate analysis and multivariate logistic regression analysis. RESULTS A total of 684 children with diarrhea under 5 years of age were enrolled, including 468 male children and 216 female children, with a mean age of (1.79 ± 1.12) years. The overall prevalence of B. hominis infection was 4.97% [34/684, 95% confidential interval (CI): (3.59%, 6.86%)] among participants, and there was no significant difference in the prevalence of B. hominis infection between children with chronic [7.52% (20/266), 95% CI: (4.92%, 11.33%)] and acute diarrhea [3.35% (14/418), 95% CI: (2.01%, 5.54%)] (χ2 = 5.983, P = 0.014). Multivariate logistic regression analysis identified keeping pet [odds ratio (OR) = 6.298, 95% CI: (2.711, 14.633)], drinking non-tap water [OR = 4.522, 95% CI: (1.769, 11.561)], lactose intolerance [OR = 4.221, 95% CI: (1.043, 17.087)], antibiotic use [OR = 0.125, 95% CI: (0.017, 0.944)] and chronic diarrhea [OR = 2.172, 95% CI: (1.018, 4.637)] as factors affecting B. hominis infection among children with diarrhea under 5 years of age in Guangzhou City. CONCLUSIONS B. hominis infections is detected in children with diarrhea under five years of age in Guangzhou City. Improving home environments and pet-keeping hygiene is recommended to reduce the likelihood of B. hominis infection among children.
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Affiliation(s)
- W R Xu
- Institute of Disease Control and Prevention of China Railway Qinghai-Aibet Group Co., Ltd., Xining, Qinghai 810007, China.,Co-first authors
| | - G S Wang
- Institute of Disease Control and Prevention of China Railway Qinghai-Aibet Group Co., Ltd., Xining, Qinghai 810007, China.,Co-first authors
| | - Q Li
- National Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention (Chinese Center for Aropical Diseases Research), National Health Commission Key Laboratory of Parasite and Vector Biology, WHO Collaborating Centre for Tropical Diseases, School of Global Health, National Center for International Research on Aropical Diseases and Shanghai Jiaotong University School of Medicine, Shanghai 200025, China
| | - J X Zheng
- National Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention (Chinese Center for Aropical Diseases Research), National Health Commission Key Laboratory of Parasite and Vector Biology, WHO Collaborating Centre for Tropical Diseases, School of Global Health, National Center for International Research on Aropical Diseases and Shanghai Jiaotong University School of Medicine, Shanghai 200025, China
| | - Z Y Guo
- National Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention (Chinese Center for Aropical Diseases Research), National Health Commission Key Laboratory of Parasite and Vector Biology, WHO Collaborating Centre for Tropical Diseases, School of Global Health, National Center for International Research on Aropical Diseases and Shanghai Jiaotong University School of Medicine, Shanghai 200025, China
| | - J X Chen
- National Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention (Chinese Center for Aropical Diseases Research), National Health Commission Key Laboratory of Parasite and Vector Biology, WHO Collaborating Centre for Tropical Diseases, School of Global Health, National Center for International Research on Aropical Diseases and Shanghai Jiaotong University School of Medicine, Shanghai 200025, China
| | - M X Chen
- National Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention (Chinese Center for Aropical Diseases Research), National Health Commission Key Laboratory of Parasite and Vector Biology, WHO Collaborating Centre for Tropical Diseases, School of Global Health, National Center for International Research on Aropical Diseases and Shanghai Jiaotong University School of Medicine, Shanghai 200025, China
| | - L G Tian
- National Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention (Chinese Center for Aropical Diseases Research), National Health Commission Key Laboratory of Parasite and Vector Biology, WHO Collaborating Centre for Tropical Diseases, School of Global Health, National Center for International Research on Aropical Diseases and Shanghai Jiaotong University School of Medicine, Shanghai 200025, China
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Sudanagunta S, Camarena-Michel A, Pennington S, Leonard J, Hoyte C, Wang GS. Comparison of Two-Bag Versus Three-Bag N-Acetylcysteine Regimens for Pediatric Acetaminophen Toxicity. Ann Pharmacother 2023; 57:36-43. [PMID: 35587124 DOI: 10.1177/10600280221097700] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Acetaminophen overdose is a leading cause of liver failure, and a leading cause of pediatric poisoning requiring hospital admission. The antidote, N-acetylcysteine (NAC), is traditionally administered as a three-bag intravenous infusion. Despite its efficacy, NAC is associated with high incidence of nonallergic anaphylactoid reactions (NAARs). Adult evidence demonstrates that alternative dosing regimens decrease NAARs and medication errors (MEs). OBJECTIVES To compare NAARs and MEs associated with two- versus three-bag NAC for acetaminophen overdose in a pediatric population. METHODS This is a retrospective observational cohort study comparing pediatric patients who received three- versus two-bag NAC for acetaminophen toxicity. The primary outcome was incidence of NAARs. Secondary outcomes were rates of MEs and relevant hospital outcomes (length of stay [LOS], intensive care unit (ICU) admission, liver transplant, death). RESULTS Two hundred forty-three patients met inclusion criteria (median age of 15 years): 150 (62%) three-bag NAC and 93 (38%) two-bag NAC. There was no difference in overall NAARs (p = 0.54). Fewer cutaneous NAARs were observed in the two-bag group, three-bag: 15 (10%), two-bag: 2 (2%), p = 0.02. MEs were significantly decreased with the two-bag regimen, three-bag: 59 (39%), two-bag: 21 (23%), p = 0.01. No statistical differences were observed in LOS, ICU admissions, transplant, or death. CONCLUSION AND RELEVANCE A significant decrease in cutaneous NAARs and MEs was observed in pediatric patients by combining the first two bags of the traditional three-bag NAC regimen. In pediatric populations, a two-bag NAC regimen for acetaminophen overdose may improve medication tolerance and safety.
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Affiliation(s)
- Sindhu Sudanagunta
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA.,Children's Hospital Colorado, Aurora, CO, USA
| | | | | | - Jan Leonard
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Christopher Hoyte
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA.,Rocky Mountain Poison and Drug Safety, Denver, CO, USA
| | - George Sam Wang
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA.,Rocky Mountain Poison and Drug Safety, Denver, CO, USA.,Children's Hospital Colorado, Aurora, CO, USA
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12
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Wang GS, Bajaj L, Poppy C, Valuck R. Integrated Prescription Drug Monitoring Program for Opioid Prescribing at a Children's Hospital. Clin Pediatr (Phila) 2022; 61:465-468. [PMID: 35442096 DOI: 10.1177/00099228221085344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- George Sam Wang
- Section of Emergency Medicine and Medical Toxicology, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO, USA
| | - Lalit Bajaj
- Section of Emergency Medicine and Medical Toxicology, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO, USA.,Department of Clinical Effectiveness, Children's Hospital Colorado, Aurora, CO, USA
| | - Christopher Poppy
- Clinical Application Services, Children's Hospital Colorado, Aurora, CO, USA
| | - Robert Valuck
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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13
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Comstock G, Kaiser S, Heard K, Wang GS. Significance of temperature in antimuscarinic toxicity: a case-control study. Clin Toxicol (Phila) 2022; 60:1070-1072. [PMID: 35735006 DOI: 10.1080/15563650.2022.2088378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Antimuscarinic toxicity can result in temperature dysregulation, but the clinical significance of this is unclear. The objective of this study was to compare peak temperatures between antimuscarinic patients with and without severe clinical outcomes. METHODS This was a case-control analysis at two large, urban, academic medical centers from January 1, 2016, through December 31, 2021. We compared peak temperature (Tmax) amongst antimuscarinic patients who experienced severe outcomes with those who did not. Severe outcome was defined as seizure, ventricular dysrhythmia, hypotension, or intubation. RESULTS Fifty-six patients met inclusion criteria of which 23 developed severe outcomes: 16 seizures, 9 cases with hypotension, 5 intubations, and 2 ventricular dysrhythmias. Tmax amongst all patients ranged from 36.4-39.2 °C. There were no fatalities. There was no difference in Tmax in the emergency department or throughout hospitalization between groups, and Tmax was not predictive for the development of severe outcomes. DISCUSSION Maximum temperatures did not differ between patients with and without severe outcomes in the setting of antimuscarinic toxicity, and temperature was poorly predictive of outcomes. Our findings suggest that mild temperature dysregulation in antimuscarinic toxicity is not a key prognostic indicator for severe outcome. Further study is needed to assess implication of severe hyperthermia.
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Affiliation(s)
| | - Sasha Kaiser
- Rocky Mountain Poison and Drug Safety, Denver, CO, USA
| | - Kennon Heard
- Emergency Medicine, University of Colorado - Anschutz Medical Campus, Aurora, CO, USA
| | - George Sam Wang
- Emergency Medicine, University of Colorado - Anschutz Medical Campus, Aurora, CO, USA
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14
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Petska HW, Yin S, Lindberg DM, Beal SJ, Drendel AL, Greiner MV, Wang GS. Drug exposures in young children - The next frontier in occult injury testing. Child Abuse Negl 2022; 127:105575. [PMID: 35276533 DOI: 10.1016/j.chiabu.2022.105575] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 02/11/2022] [Accepted: 02/17/2022] [Indexed: 06/14/2023]
Affiliation(s)
- Hillary W Petska
- Medical College of Wisconsin, Milwaukee, WI, United States of America; Children's Hospital of Wisconsin, Milwaukee, WI, United States of America.
| | - Shan Yin
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States of America; University of Cincinnati College of Medicine, Cincinnati, OH, United States of America
| | - Daniel M Lindberg
- University of Colorado - Anschutz Medical Campus, Aurora, CO, United States of America
| | - Sarah J Beal
- University of Cincinnati College of Medicine, Cincinnati, OH, United States of America; University of Colorado - Anschutz Medical Campus, Aurora, CO, United States of America
| | - Amy L Drendel
- Medical College of Wisconsin, Milwaukee, WI, United States of America; Children's Hospital of Wisconsin, Milwaukee, WI, United States of America
| | - Mary V Greiner
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States of America; University of Cincinnati College of Medicine, Cincinnati, OH, United States of America
| | - George Sam Wang
- University of Colorado - Anschutz Medical Campus, Aurora, CO, United States of America
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15
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Wang GS, Buttorff C, Wilks A, Schwam D, Tung G, Pacula RL. Impact of cannabis legalization on healthcare utilization for psychosis and schizophrenia in Colorado. Int J Drug Policy 2022; 104:103685. [PMID: 35429874 DOI: 10.1016/j.drugpo.2022.103685] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 03/18/2022] [Accepted: 04/02/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Emergency department (ED) visits involving psychosis and schizophrenia have increased at a rate exceeding population growth in the United States over the past decade. Research shows a strong dose-response relationship between chronic use of high-potency cannabis and odds of developing symptoms of psychosis. The aim of this study was to evaluate the impact of cannabis legalization on psychosis and schizophrenia-related ED visits in Colorado. METHODS Using administrative data from Colorado Hospital Association (CHA) on county-level quarterly ED visits between January 1, 2013, and December 31, 2018, we applied a difference-in-difference analysis to examine how new exposure to recreational cannabis dispensaries after 2014 differentially influenced the rate of ED visits for psychosis and schizophrenia, comparing counties with no prior medical cannabis dispensary exposure to counties with low or high medical dispensary exposure. RESULTS As recreational dispensaries per 10,000 residents increased, there was no significant association with the rate of schizophrenia ED visits per capita (incidence rate ratio or IRR: 0.95, 95% CI [0.69, 1.30]) while the rate of psychosis visits increased 24% (IRR: 1.24, 95% CI [1.02, 1.49]). Counties with no previous medical dispensaries experienced larger increases in schizophrenia ED visits than counties already exposed to a low level of medical dispensaries, but this effect was not significant. Counties with low baseline medical exposure had lower increases in rates of psychosis visits than counties with high baseline medical exposure (IRR 0.83, 95% CI [0.69, 0.99]). CONCLUSIONS There was a positive association between the number of cannabis dispensaries and rates of psychosis ED visits across all counties in Colorado. Although it is unclear whether it is access to products, or the types of products that may be driving this association, our findings suggest there is a potential impact on the mental health of the local population that is observed after cannabis legalization.
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Affiliation(s)
- George Sam Wang
- University of Colorado Anschutz Medical Campus Children's, Hospital Colorado Department of Pediatrics 13123 East 16th Ave B251 Aurora CO 80045, United States.
| | | | - Asa Wilks
- RAND Corporation, 1776 Main Street Santa Monica, CA 90407, United States.
| | - Daniel Schwam
- RAND Corporation, 1200 S. Hayes St Arlington VA 22202, United States.
| | - Gregory Tung
- University of Colorado Anschutz Medical Campus Colorado School of Public Health Department of Health Systems, Management & Policy Program for Injury Prevention, Education and Research (PIPER) Colorado School of Public Health, 13001 E. 17th Place, MS B119, United States.
| | - Rosalie Liccardo Pacula
- University of Southern California Sol Price School of Public Policy, Schaeffer Center for Health Policy & Economics 635 Downey Way, VPD 514J, Los Angeles, CA 90089-3333, United States.
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16
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Comstock G, Kilgallon K, Wang GS, Bourne D, Blanchette E, Stenson E. Management and Associated Toxicokinetics of Massive Valproic Acid Ingestion with High Flow Continuous Venovenous Hemodiafiltration. J Med Toxicol 2022; 18:239-242. [PMID: 35235162 DOI: 10.1007/s13181-022-00881-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 01/24/2022] [Accepted: 01/25/2022] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Valproic acid (VPA) toxicity commonly results in a self-limited state of CNS depression that is managed with supportive care and levocarnitine. In massive overdose, patients can develop toxic encephalopathy, shock, multisystem organ failure, and death. We present a case with relevant toxicokinetics of a patient presenting with a profoundly elevated VPA concentration resulting in survival, treated with supportive care including high-dose continuous venovenous hemodiafiltration (CVVHDF). CASE REPORT A 17-year-old female presented to an emergency department after being found unresponsive at home with concern for massive VPA ingestion. She arrived obtunded and hypotensive with initial VPA concentration of 2226 mg/L, estimated 9 h post-ingestion. Her early hospital course was marked by hypotension requiring multiple vasopressors, and her workup was notable for multiple severe metabolic derangements. High-dose CVVHDF was initiated upon transfer to a tertiary children's hospital with the aim to enhance VPA removal and normalize metabolic derangements. At that time, her VPA concentration was 1071 mg/L. Apparent half-life of VPA improved modestly with extracorporeal treatment, but her metabolic derangements and hemodynamic instability corrected rapidly. Her clinical course was complicated by necrotizing pancreatitis, pancytopenia requiring transfusions of multiple cell lines, coma, and seizures. She ultimately recovered with normal neurological function.
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Affiliation(s)
- Grant Comstock
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, 1391 Speer Blvd, Unit 600, Denver, CO, USA.
| | - Kevin Kilgallon
- Children's Hospital Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - George Sam Wang
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, 1391 Speer Blvd, Unit 600, Denver, CO, USA
| | - David Bourne
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Eliza Blanchette
- Children's Hospital Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Erin Stenson
- Children's Hospital Colorado Anschutz Medical Campus, Aurora, CO, USA
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Wang GS, Buttorff C, Wilks A, Schwam D, Metz TD, Tung G, Pacula RL. Cannabis legalization and cannabis-involved pregnancy hospitalizations in Colorado. Prev Med 2022; 156:106993. [PMID: 35150750 PMCID: PMC8956031 DOI: 10.1016/j.ypmed.2022.106993] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 12/09/2021] [Accepted: 02/06/2022] [Indexed: 11/16/2022]
Abstract
The primary objective of this study was to evaluate the association between presence of recreational cannabis dispensaries and prevalence of cannabis-involved pregnancy hospitalizations in Colorado. This was a retrospective cohort study of pregnancy-related hospitalizations co-coded with cannabis diagnosis codes in the Colorado Hospital Association from January 1, 2011, through December 31, 2018 (recreational cannabis began January 1, 2014). Our primary outcome was cannabis-involved pregnancy hospitalizations per 10 k live births per county. The primary exposure measure was county variation in the number of recreational dispensaries. We controlled for counties' baseline exposure to medical cannabis dispensaries and used Poisson regression to evaluate the association between exposure to recreational cannabis and hospitalizations. During the study period, cannabis-involved pregnancy hospitalizations increased from 429 to 1210. Mean hospitalizations per county (1.7 to 4.7) and per 10 k live births (13.2 to 55.7) increased. Overall, increasing recreational dispensaries were associated with increases in hospitalizations (1.02, CI: 1.00,1.04). When comparing counties with different densities of baseline medical cannabis market, low and high exposure counties had fewer hospitalizations than those counties with no exposure (low: IRR 0.97, CI: 0.96-0.99; high: 0.98, CI: 0.96-0.99). In Colorado, there was more than a two-fold increase in cannabis-involved pregnancy hospitalizations between 2011 and 2018. Counties with no baseline exposure to medical cannabis had a greater increase than other counties, suggesting the recreational market may influence cannabis use among pregnant individuals.
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Affiliation(s)
- George Sam Wang
- University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Department of Pediatrics, 13123 East 16th Ave B251, Aurora, CO 80045, United States of America.
| | - Christine Buttorff
- RAND Corporation, 1200 S. Hayes St, Arlington, VA 22202, United States of America.
| | - Asa Wilks
- RAND Corporation, 1776 Main Street, Santa Monica, CA 90407, United States of America.
| | - Daniel Schwam
- RAND Corporation, 1200 S. Hayes St, Arlington, VA 22202, United States of America.
| | - Torri D Metz
- University of Utah Health, 50 Medical Dr N, Salt Lake City, UT 84132, United States of America.
| | - Gregory Tung
- University of Colorado Anschutz Medical Campus, Colorado School of Public Health, Department of Health Systems, Management & Policy, Program for Injury Prevention, Education and Research (PIPER), Colorado School of Public Health, 13001 E. 17th Place, MS B119, United States of America.
| | - Rosalie Liccardo Pacula
- University of Southern California, Sol Price School of Public Policy, Schaeffer Center for Health Policy & Economics, 635 Downey Way, VPD 514J, Los Angeles, CA 90089-3333, United States of America.
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Wang GS, Buttorff C, Wilks A, Schwam D, Tung G, Banerji S, Dart RC, Pacula RL. Comparison of hospital claims and poison center data to evaluate health impact of opioids, cannabis and synthetic cannabinoids. Am J Emerg Med 2022; 53:150-153. [PMID: 35051702 PMCID: PMC8956045 DOI: 10.1016/j.ajem.2022.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 12/29/2021] [Accepted: 01/07/2022] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Over the past 10 years, opioids and cannabis have garnered significant attention due to misuse and legalization trends. Different datasets and surveillance mechanisms can lead to different conclusions the due to a variety of factors. The primary objective of this study was to compare and describe trends of opioid, cannabis, and synthetic cannabinoid-related healthcare encounters and poison center (PC) cases in Colorado, a state that has legalized cannabis. METHODS This was a retrospective study comparing hospital claims data (Colorado Hospital Association (CHA)) and poison center cases to describe opioid, cannabis and synthetic cannabinoid-related healthcare encounters and exposures in Colorado from 2013 to 2017 using related genetic codes and International Statistical Classification of Disease codes. RESULTS Both datasets observed increases in cannabis related encounters and exposures after recreational cannabis legalization in 2014. CHA reported an increase for cannabis-related ER visits from 14,109 in 2013 to 18,118 in 2017 while PC noted a 74.4% increase in cannabis-related cases (125 to 218). CHA inpatient visits associated with cannabis also increased (8311 in 2013 to 14,659 in 2017). On the other hand, Opioid-related exposures to the PC fell (1092 in 2013 to 971 in 2017) while both Opioid-related ER visits (8580 in 2013 to 12,928 in 2017) and inpatient visits in CHA increased (9084 in 2013 to 13,205). CONCLUSIONS This study demonstrates the differences in surveillance methodology for concurrent drug abuse epidemics using hospital claims and PC data. Both systems provide incomplete reports, but in combination can provide a more complete picture.
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Affiliation(s)
- George Sam Wang
- University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Department of Pediatrics, 13123 East 16th Ave B251, Aurora, CO 80045, United States of America.
| | | | - Asa Wilks
- RAND Corporation, United States of America.
| | | | - Greg Tung
- University of Colorado Anschutz Medical Campus, Colorado School of Public Health, Department of Health Systems, Management & Policy
| | - Shireen Banerji
- Rocky Mountain Poison and Drug Safety, Denver Health Hospital AuthorityShireen, United States of America.
| | - Richard C Dart
- Rocky Mountain Poison and Drug Safety, Denver Health Hospital Authority
| | - Rosalie Liccardo Pacula
- University of Southern California, Sol Price School of Public Policy, Schaeffer Center for Health Policy & Economics, United States of America.
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Wang GS, Reynolds KM, Banner W, Bond GR, Kauffman RE, Palmer RB, Paul IM, Rapp-Olsson M, Green JL, Dart RC. Adverse Events Related to Accidental Unintentional Ingestions From Cough and Cold Medications in Children. Pediatr Emerg Care 2022; 38:e100-e104. [PMID: 32576790 DOI: 10.1097/pec.0000000000002166] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Previous research has demonstrated that accidental unsupervised ingestions (AUIs) were responsible for the majority of cough and cold medication (CCM) ingestions leading to significant adverse events (AEs) in children. The objective of this analysis was to characterize the role of AUIs in the morbidity associated with CCM exposure in children. METHODS This surveillance study collected data from 5 United States data sources from 2009 to 2016, in children younger than 6 years with an AE from an AUI involving at least 1 CCM over-the-counter pharmaceutical ingredient. An expert panel reviewed each case to determine causality. RESULTS From 4756 total cases reviewed, 3134 (65.9%) had an AE from an AUI determined to be at least potentially related to a CCM ingredient. The majority (61.3%) of cases occurred in children aged 2 to younger than 4 years. Most exposures occurred in the child's own residence (94.9%), and 43.8% were admitted to a health care facility (22.0% to a critical care unit). Dextromethorphan and diphenhydramine, when packaged alone or in combination products, contributed to 96.0% of AUIs. The most common specific products involved were single-ingredient pediatric liquid diphenhydramine (30.1%) and single-ingredient pediatric liquid dextromethorphan (21.4%). There were 3 deaths from solid diphenhydramine formulations. CONCLUSIONS There continues to be opportunities for the implementation of interventions to prevent AUIs of CCM in children. Additional emphasis on engineering controls, such as flow restrictors for liquid formulations targeting diphenhydramine and dextromethorphan products, represent additional opportunities to further reduce AEs from AUIs of CCM.
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Affiliation(s)
| | - Kate M Reynolds
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO
| | - William Banner
- Oklahoma Center for Poison and Drug Information, Oklahoma University College of Pharmacy, Oklahoma City, OK
| | - G Randall Bond
- Faculté de Médecine, Hope Africa University, Bujumbura, Burundi
| | - Ralph E Kauffman
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO
| | - Robert B Palmer
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO
| | - Ian M Paul
- Pediatrics and Public Health Sciences, Penn State College of Medicine, Hershey, PA
| | - Malin Rapp-Olsson
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO
| | | | - Richard C Dart
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO
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20
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Wang GS, Reese J, Bakel LA, Leonard J, Bos T, Bielsky A, Nickels S, Bajaj L. Prescribing Patterns of Oral Opioid Analgesic for Long Bone Fracture at Tertiary Care Children's Hospital Emergency Departments and Urgent Cares. Pediatr Emerg Care 2021; 37:e1524-e1527. [PMID: 32384393 DOI: 10.1097/pec.0000000000002105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Disparities in opioid prescribing in children can lead to underprescribing and poorly controlled pain. On the contrary, unnecessary overprescribing can increase the risk for misuse, abuse, and diversion. The primary objective of this study was to compare the demographics and clinical characteristics of children with an extremity fracture who did and did not receive an opioid prescription from a tertiary care children's hospital. METHODS This was a retrospective cohort study of children younger than 22 years with extremity fracture evaluated at a tertiary care children's hospital emergency department (ED) and surrounding satellite locations (3 EDs and 4 urgent cares), from January 1, 2017, to December 31, 2017. RESULTS There were 3325 patients younger than 22 years who were seen for evaluation of an extremity fracture. The overall median age of patients was 8 years (interquartile range [IQR], 4-11), and 1976 (59.4%) were male. Patients with extremity fractures who received opioid analgesics were older than those who did not receive opioids (median age of 10 years [IQR, 6-13 years] vs 7 years [IQR, 4-11 years], P < 0.001). There was a significant difference found between insurance types, specifically those patients receiving Medicaid and private insurance. Patients who received opioid analgesics had a higher initial pain score (7 [IQR, 4-9] vs 5 [IQR, 2-7], P < 0.001), were more likely to have an physician (MD/DO) provider (P < 0.001), and were more likely to present to the ED (P < 0.001). CONCLUSIONS Younger patients, patients with Medicaid insurance, patients treated by an advanced care provider, and patients who presented to an urgent care were less likely to receive opioid analgesics upon discharge. These findings demonstrate that more standardization and guidance on opioid prescribing are needed in pediatrics, to both adequately treat pain and reduce harms from overprescribing of opioid analgesics.
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Affiliation(s)
| | - Jennifer Reese
- Division of Hospitalist Medicine, University of Colorado Anschutz Medical Campus
| | | | - Jan Leonard
- Division of Emergency Medicine, University of Colorado Anschutz Medical Campus
| | - Tod Bos
- Department of Clinical Effectiveness, Children's Hospital Colorado
| | - Alan Bielsky
- Department of Anesthesia, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Sarah Nickels
- Department of Clinical Effectiveness, Children's Hospital Colorado
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Wang GS, Reese J, Bakel LA, Leonard J, Bielsky A, Reid A, Bos T, Nickels S, Bajaj L. Prescribing Patterns of Oral Opioid Analgesic for Acute Pain at a Tertiary Care Children's Hospital Emergency Departments and Urgent Cares. Pediatr Emerg Care 2021; 37:e841-e845. [PMID: 31688834 DOI: 10.1097/pec.0000000000001909] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVES Despite Centers for Disease Control and Prevention guidelines on adult opioid prescribing, there is a paucity of evidence and no guidelines to inform opioid prescribing in pediatrics. To develop guidelines on pediatric prescribing, it is imperative to evaluate current practice on opioid use. The objectives were to describe prescribing patterns of opioids for acute pain at a children's hospital and to compare clinical characteristics of patients who received less or greater than 3 days. METHODS A retrospective review of oral opioid analgesics prescribed for acute pain at a tertiary care children's hospital emergency department and urgent care from January 1, 2017, to December 31, 2017. Patients younger than 22 years who received an opioid prescription upon discharge were included. Patients with hematology/oncology or chronic pain diagnosis were excluded. RESULTS Opioids were prescribed for a median of 2.2 days (interquartile range, 1.4-3.0 days). Most opioids were prescribed for ≤3 days (1326; 79.3%), and there were 44 (2.6%) prescriptions for >7 days. Twenty-two opioid formulations were prescribed. Single-ingredient oxycodone was the most commonly prescribed (877; 52.5%); there were 724 (43.3%) acetaminophen combination products. Common diagnoses were orthopedic (973; 58.2%), surgery/burn/trauma (195; 11.7%), and ear/nose/throat (143; 8.6%). Patients who received >3 days of opioids were younger (P < 0.001), and there was no differences in sex, ethnicity, insurance, or provider qualifications. CONCLUSIONS Overall, prescribing patterns for the duration of opioid analgesics were ≤3 days, with a median of 2 days. There was a large range of days prescribed, with variations in prescribing characteristics among patients and providers.
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Halmo LS, Wang GS, Reynolds KM, Delva-Clark H, Rapp-Olsson M, Banner W, Bond GR, Kauffman RE, Palmer RB, Paul IM, Green JL, Dart RC. Pediatric Fatalities Associated With Over-the-Counter Cough and Cold Medications. Pediatrics 2021; 148:peds.2020-049536. [PMID: 34607934 DOI: 10.1542/peds.2020-049536] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/26/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES In 2008, over-the-counter cough and cold medications (CCMs) underwent labeling changes in response to safety concerns, including fatalities, reported in children exposed to CCMs. The objective of this study is to describe fatalities associated with exposures to CCMs in children <12 years old that were detected by a safety surveillance system from 2008 to 2016. METHODS Fatalities in children <12 years old that occurred between 2008 and 2016 associated with oral exposure to one or more CCMs were identified by the Pediatric Cough and Cold Safety Surveillance System. An expert panel reviewed all cases to determine the causal relationship between the exposure and death, if the intent of exposure was therapeutic, and if the dose was supratherapeutic. Other contributing factors related to the child's death were also identified as part of a root cause analysis. RESULTS Of the 180 eligible fatalities captured during the study period, 40 were judged by the expert panel to be either related or potentially related to the CCM. Of these, the majority (n = 24; 60.0%) occurred in children <2 years old and involved nontherapeutic intent (n = 22; 55.0%). The most frequently involved index ingredient was diphenhydramine (n = 28; 70.0%). In 6 cases (n = 6; 15.0%), the CCM was administered to murder the child. In another 7 cases (n = 7; 17.5%), death followed the intentional use of the CCM to sedate the child. CONCLUSIONS Pediatric fatalities associated with CCMs occurred primarily in young children after deliberate medication administration with nontherapeutic intent by a caregiver.
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Affiliation(s)
- Laurie Seidel Halmo
- Department of Pediatrics, Children's Hospital Colorado and University of Colorado Anschutz Medical Campus, Aurora, Colorado.,Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, Colorado
| | - George Sam Wang
- Department of Pediatrics, Children's Hospital Colorado and University of Colorado Anschutz Medical Campus, Aurora, Colorado.,Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, Colorado
| | - Kate M Reynolds
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, Colorado;
| | - Heather Delva-Clark
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, Colorado.,CPC Clinical Research, Aurora, Colorado
| | - Malin Rapp-Olsson
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, Colorado
| | - William Banner
- Oklahoma Center for Poison and Drug Information and College of Pharmacy, The University of Oklahoma Health Sciences Center, The University of Oklahoma, Oklahoma City, Oklahoma
| | - G Randall Bond
- Faculté de Médecine, Hope Africa University, Bujumbura, Burundi
| | - Ralph E Kauffman
- Department of Pediatrics, School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Robert B Palmer
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, Colorado
| | - Ian M Paul
- Departments of Pediatrics and Public Health Sciences, College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania; and
| | - Jody L Green
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, Colorado.,Inflexxion, Costa Mesa, California
| | - Richard C Dart
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, Colorado
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Abstract
IMPORTANCE Cannabis hyperemesis syndrome is an emerging clinical issue associated with cannabis use. Legalization of cannabis has led to an increase in vomiting-related illnesses in health care settings. OBJECTIVE To examine whether legalization of cannabis in Colorado has been associated with increases in vomiting-related emergency department (ED) visits. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional design was used to assess the increase in ED claims for vomiting reported to the Colorado Hospital Association between January 1, 2013, and December 31, 2018, in counties that had no prior cannabis dispensaries before legalization compared with those that did. A total of 820 778 patients seeking care through Colorado EDs were included in the analysis. EXPOSURES The number of medical and recreational cannabis dispensaries per county per quarter. MAIN OUTCOMES AND MEASURES County per capita rate of vomiting-related ED claims per quarter. RESULTS Vomiting-related ED health care encounters increased from 119 312 in 2013 to 153 699 in 2018 (29% increase). Over this period, 203 861 patients (25%) were aged 0 to 18 years; 114 201 (14%) were aged 19 to 25 years, and 502 771 (61%) were aged 26 years or older; 510 584 patients (62%) were female. Additional recreational dispensaries were associated with increased vomiting-related ED visits (incidence rate ratio, 1.03; 95% CI, 1.01-1.05), but counties with high baseline medical dispensary exposure experienced smaller increases in vomiting-related ED visits than counties with no baseline medical dispensary exposure (incidence rate ratio, 0.97; 95% CI, 0.95-0.99). Counties with a high number of medical marijuana dispensaries had increases at a 5.8% slower rate than counties with none. CONCLUSIONS AND RELEVANCE The findings of this study suggest that cannabis legalization in Colorado is associated with an increase in annual vomiting-related health care encounters with regard to exposure to these markets. It may be useful for health care clinicians to be aware of cannabis hyperemesis syndrome and inquire about cannabis use when appropriate.
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Affiliation(s)
- George Sam Wang
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora
| | | | - Asa Wilks
- RAND Corporation, Santa Monica, California
| | | | - Gregory Tung
- Department of Health Systems, Management & Policy, Colorado School of Public Health, University of Colorado Anschutz Medical Campus
| | - Rosalie Liccardo Pacula
- Sol Price School of Public Policy, Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles
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Brooks-Russell A, Brown T, Friedman K, Wrobel J, Schwarz J, Dooley G, Ryall KA, Steinhart B, Amioka E, Milavetz G, Sam Wang G, Kosnett MJ. Simulated driving performance among daily and occasional cannabis users. Accid Anal Prev 2021; 160:106326. [PMID: 34403895 PMCID: PMC8409327 DOI: 10.1016/j.aap.2021.106326] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 06/05/2021] [Accepted: 07/28/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE Daily cannabis users develop tolerance to some drug effects, but the extent to which this diminishes driving impairment is uncertain. This study compared the impact of acute cannabis use on driving performance in occasional and daily cannabis users using a driving simulator. METHODS We used a within-subjects design to observe driving performance in adults age 25 to 45 years with different cannabis use histories. Eighty-five participants (43 males, 42 females) were included in the final analysis: 24 occasional users (1 to 2 times per week), 31 daily users and 30 non-users. A car-based driving simulator (MiniSim™, National Advanced Driving Simulator) was used to obtain two measures of driving performance, standard deviation of lateral placement (SDLP) and speed relative to posted speed limit, in simulated urban driving scenarios at baseline and 30 min after a 15 min ad libitum cannabis smoking period. Participants smoked self-supplied cannabis flower product (15% to 30% tetrahydrocannabinol (THC). Blood samples were collected before and after smoking (30 min after the start of smoking). Non-users performed the same driving scenarios before and after an equivalent rest interval. Changes in driving performance were analyzed by repeated measures general linear models. RESULTS Mean whole blood THC cannabinoids concentrations post smoking were use THC = 6.4 ± 5.6 ng/ml, THC-COOH = 10.9 ± 8.79 ng/mL for occasional users and THC = 36.4 ± 37.4 ng/mL, THC-COOH = 98.1 ± 90.6 ng/mL for daily users. On a scale of 0 to 100, the mean post-use score of subjective high was similar in occasional users and daily users (52.4 and 47.2, respectively). In covariate-adjusted analysis, occasional users had a significant increase in SDLP in the straight road segment from pre to post compared to non-users; non-users decreased by a mean of 1.1 cm (25.5 cm to 24.4 cm) while occasional users increased by a mean of 1.9 cm (21.7 cm to 23.6 cm; p = 0.02). Daily users also increased adjusted SDLP in straight road segments from baseline to post-use (23.2 cm to 25.0 cm), but the change relative to non-users was not statistically significant (p = 0.08). The standardized mean difference in unadjusted SDLP from baseline to post-use in the straight road segments comparing occasional users to non-users was 0.64 (95% CI 0.09 - 1.19), a statistically significant moderate increase. When occasional users were contrasted with daily users, the baseline to post changes in SDLP were not statistically significant. Daily users exhibited a mean decrease in baseline to post-use adjusted speed in straight road segments of 1.16 mph; a significant change compared to slight speed increases in the non-users and occasional users (p = 0.02 and p = 0.01, respectively). CONCLUSION We observed a decrement in driving performance assessed by SDLP after acute cannabis smoking that was statistically significant only in the occasional users in comparison to the nonusers. Direct contrasts between the occasional users and daily users in SDLP were not statistically significant. Daily users drove slower after cannabis use as compared to the occasional use group and non-users. The study results do not conclusively establish that occasional users exhibit more driving impairment than daily users when both smoke cannabis ad libitum.
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Affiliation(s)
- Ashley Brooks-Russell
- Department of Community and Behavioral Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Tim Brown
- National Advanced Driving Simulator, University of Iowa, Iowa City, IA, United States
| | - Kyle Friedman
- Rocky Mountain Poison and Drug Safety, Denver Health, Denver, CO, United States
| | - Julia Wrobel
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - John Schwarz
- Rocky Mountain Poison and Drug Safety, Denver Health, Denver, CO, United States
| | - Gregory Dooley
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO, United States
| | - Karen A Ryall
- Rocky Mountain Poison and Drug Safety, Denver Health, Denver, CO, United States
| | - Benjamin Steinhart
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Elise Amioka
- Rocky Mountain Poison and Drug Safety, Denver Health, Denver, CO, United States
| | - Gary Milavetz
- National Advanced Driving Simulator, University of Iowa, Iowa City, IA, United States
| | - George Sam Wang
- Department of Pediatrics, CU School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Michael J Kosnett
- Department of Medicine, CU School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States; Department of Environmental and Occupational Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
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Hunter K, Poel K, Pennington S, Bindseil I, Banerji S, Leonard J, Wang GS. Trends of prescription psychotropic medication exposures in pediatric patients, 2009-2018. Clin Toxicol (Phila) 2021; 60:243-251. [PMID: 34196239 DOI: 10.1080/15563650.2021.1946556] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Mental health disorders and related suicide attempts are increasing in both the adult and pediatric patient populations. Because of the increasing prevalence of mental health disorders, there is increased use of psychotropic medications in adult and pediatric patients, which can pose a risk for potentially adverse pediatric ingestions. The objective was to determine trends and outcomes for pediatric psychotropic medication ingestions reported to the American Association of Poison Control Centers (AAPCC) National Poison Data System (NPDS). METHODS This was a retrospective review of pediatric (≤18 years of age) exposures reported to AAPCC NPDS between January 1, 2009 and December 31, 2018. Single psychotropic medication ingestions of atypical antipsychotics, bupropion, buspirone, clonidine, lithium, methylphenidate, mirtazapine, monoamine oxidase inhibitors (MAOIs), selective norepinephrine reuptake inhibitors (SNRIs), selective serotonin reuptake inhibitors (SSRIs), trazodone, and tricyclic antidepressants (TCAs) were examined. RESULTS Over the 10-year study period, 356,548 pediatric psychotropic medication ingestions were reported to NPDS. SSRI ingestions were the most frequently reported (34%), followed by atypical antipsychotics (17%), and methylphenidate (15%). Unintentional ingestions were most prominent in patients 0-12 years of age (79%), whereas, in patients age 13-18 years, 76% were intentional. SSRI ingestions were asymptomatic in 68% of cases. Clonidine and bupropion ingestions had the highest proportion of moderate and major clinical effects (29 and 25%, respectively). There were 29 deaths: atypical antipsychotics (n = 4), bupropion (n = 10), lithium (n = 1), SNRI (n = 1), SSRIs (n = 7), and TCAs (n = 6); 19 (65%) were in adolescent patients. CONCLUSIONS SSRIs were the most frequently reported ingestion, while bupropion and clonidine were associated with a high percentage of moderate and major clinical effects. This study demonstrates opportunities for targeted prevention strategies to prevent potentially adverse pediatric ingestions to psychotropic medications.
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Affiliation(s)
- Kiley Hunter
- Department of Pharmacy, Le Bonheur Children's Hospital, Memphis, TN, USA
| | - Kevin Poel
- Section of Emergency Medicine, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO, USA
| | - Stephanie Pennington
- Section of Emergency Medicine, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO, USA
| | - Isabelle Bindseil
- Department of Pharmacy, Children's Hospital Colorado, Aurora, CO, USA
| | - Shireen Banerji
- Rocky Mountain Poison and Drug Safety, Denver Health Hospitals, Denver, CO, USA
| | - Jan Leonard
- Section of Emergency Medicine, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO, USA
| | - George Sam Wang
- Section of Emergency Medicine, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO, USA
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Sempio C, Almaraz-Quinones N, Jackson M, Zhao W, Wang GS, Liu Y, Leehey M, Knupp K, Klawitter J, Christians U, Klawitter J. Simultaneous Quantification of 17 Cannabinoids bY LC-MS-MS in Human Plasma. J Anal Toxicol 2021; 46:383-392. [PMID: 33754154 DOI: 10.1093/jat/bkab030] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 03/09/2021] [Accepted: 03/22/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND In recent years, the surge in use and of clinical trials involving tetrahydrocannabinol (THC) and cannabidiol (CBD) has increased the need for sensitive and specific analytical assays to measure said compounds in patients, to establish dose-effect relationships and to gain knowledge of their pharmacokinetics and metabolism. We developed and validated an online extraction high-performance liquid chromatography- tandem mass spectrometry (LC-MS/MS) method for simultaneous quantification of 17 cannabinoids and metabolites including THC and its metabolites, CBD and its metabolites and other minor cannabinoids in human plasma. METHODS CBD-glucuronide (CBD-gluc) standard was produced in-house by isolation of CBD-gluc from urine of patients using pure CBD oil. For calibration standards and quality control samples, human plasma was spiked with cannabinoids at varying concentrations within the working range of the respective compound and 200 µL was extracted using a simple one-step protein precipitation procedure. The extracts were analyzed using online trapping LC/LC-atmospheric pressure chemical ionization (APCI)-MS/MS running in the positive multiple reaction monitoring (MRM) mode. RESULTS The lower limit of quantification ranged from 0.78 ng/mL to 7.8 ng/mL and the upper limits of quantification were between 100 ng/mL and 2000 ng/mL. Inter-day analytical accuracy and imprecision ranged from 90.4 to 111% and from 3.1 to 17.4%, respectively. The analysis of plasma samples collected during clinical studies showed that (3R-trans)-Cannabidiol-7-oic Acid (7-CBD-COOH) was the major human metabolite with 5960% of CBD followed by 7-hydroxy-CBD (177%), CBD-gluc (157%) and 6α-hydroxy-CBD (39.8%); 6β-hydroxy-CBD was not detected in any of the samples. CONCLUSIONS In the present study, we developed and validated a robust LC-MS/MS assay for the simultaneous quantification of cannabinoids and their metabolites, which has been used to measure >5,000 samples in clinical studies. Moreover, we were able to quantify CBD-gluc and showed that 7-CBD-COOH, 7-hydroxy-CBD and CBD-gluc are the major CBD metabolites in human plasma.
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Affiliation(s)
- Cristina Sempio
- Department of Anesthesiology, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Nohemi Almaraz-Quinones
- Department of Anesthesiology, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Matthew Jackson
- Department of Anesthesiology, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Wanzhu Zhao
- Department of Anesthesiology, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - George Sam Wang
- Section of Emergency Medicine and Medical Toxicology, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO, 80045, USA
| | - Ying Liu
- Department of Neurology, University of Colorado, Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Maureen Leehey
- Department of Neurology, University of Colorado, Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Kelly Knupp
- Department of Neurology and Pediatrics, University of Colorado, Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO 80045, USA
| | - Jelena Klawitter
- Department of Anesthesiology, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Uwe Christians
- Department of Anesthesiology, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Jost Klawitter
- Department of Anesthesiology, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
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Fredericks RM, Wang GS, Vohwinkel CU, Graham JK. An Unusual Case of Severe Anion Gap Metabolic Acidosis in a 3-year-old Girl. Pediatr Rev 2021; 42:S46-S51. [PMID: 33386361 DOI: 10.1542/pir.2019-0111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Ryan M Fredericks
- Children's Hospital Colorado, Section of Pediatric Critical Care Medicine,
| | - George Sam Wang
- Section of Emergency Medicine, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO
| | | | - Jessica Kraynik Graham
- Section of Emergency Medicine, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO
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28
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Wang GS, Baker K, Ng P, Janis GC, Leonard J, Mistry RD, Heard K. A randomized trial comparing physostigmine vs lorazepam for treatment of antimuscarinic (anticholinergic) toxidrome. Clin Toxicol (Phila) 2020; 59:698-704. [DOI: 10.1080/15563650.2020.1854281] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- George Sam Wang
- Section of Emergency Medicine, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children’s Hospital Colorado, Aurora, CO, USA
| | - Keith Baker
- Departments of Emergency Medicine and Medical Toxicology, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Patrick Ng
- En route Care Research Center, Lackland AFB, San Antonio, TX, USA
| | - Gregory C. Janis
- MedTox Laboratories, Laboratory Corporation of America Holdings, Saint Paul, MN, USA
| | - Jan Leonard
- Section of Emergency Medicine, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children’s Hospital Colorado, Aurora, CO, USA
| | - Rakesh D. Mistry
- Section of Emergency Medicine, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children’s Hospital Colorado, Aurora, CO, USA
| | - Kennon Heard
- Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, University of Colorado Hospital, Aurora, CO, USA
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29
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Wang GS, Green JL, Reynolds KM, Banner W, Bond GR, Kauffman RE, Palmer RB, Paul IM, Rapp-Olsson M, Dart RC. Trends in adverse events and related health-care facility utilization from cough and cold medication exposures in children. Clin Toxicol (Phila) 2020; 59:351-354. [PMID: 32914676 DOI: 10.1080/15563650.2020.1815761] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Initial research following regulatory changes addressing the pediatric safety of cough and cold medications (CCMs) demonstrated decreases in adverse events (AEs). Using a national multi-source surveillance system, we studied subsequent CCM-related AE case rate trends and associated health-care facility (HCF) evaluation in children. METHODS Data were collected from 2009 to 2016. Case eligibility included: age <12 years; exposure to an over-the-counter product containing ≥1 CCM pharmaceutical ingredient; ≥1 significant AE that occurred in the United States. RESULTS About 4756 (72.6%) cases were determined at least potentially related to an index ingredient. Accidental unsupervised ingestions (AUIs; 3134; 65.9%) were the most common case type. Nearly half of AE cases involved children 2 to <4 years old (2,159; 45.4%). The AE case rate did not change significantly over time (p = 0.22). The proportion of AE cases resulting in HCF admission increased from 32.4% (207) in 2009 to 43.4% (238) in 2016 (p < 0.01). Exposures to diphenhydramine (1,305; 67.3%) and/or dextromethorphan (591; 30.5%) were involved in the majority of HCF admissions. CONCLUSIONS The proportion of AE cases resulting in HCF admission increased from 2009 to 2016. Efforts to prevent AUIs such as packaging innovation and engineering controls, particularly for diphenhydramine and dextromethorphan-containing products, should be pursued.
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Affiliation(s)
- George Sam Wang
- Department of Pediatrics, Children's Hospital Colorado, Aurora, CO, USA.,Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO, USA
| | - Jody L Green
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO, USA
| | - Kate M Reynolds
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO, USA
| | - William Banner
- Oklahoma Center for Poison and Drug Information, Oklahoma University College of Pharmacy, Oklahoma City, OK, USA
| | - G Randall Bond
- Faculté de Médecine, Hope Africa University, Bujumbura, Burundi
| | - Ralph E Kauffman
- Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - Robert B Palmer
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO, USA
| | - Ian M Paul
- Pediatrics & Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Malin Rapp-Olsson
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO, USA
| | - Richard C Dart
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO, USA
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30
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Wang GS, Reynolds KM, Banner W, Bond GR, Kauffman RE, Palmer RB, Paul IM, Rapp-Olsson M, Green JL, Dart RC. Medication Errors From Over-the-Counter Cough and Cold Medications in Children. Acad Pediatr 2020; 20:327-332. [PMID: 31562931 DOI: 10.1016/j.acap.2019.09.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 09/14/2019] [Accepted: 09/22/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Out of hospital medication-related adverse events (AEs) from cough and cold medications (CCMs) can have significant public health impact. The objective of this study was to characterize pediatric medication error AEs involving over-the-counter (OTC) CCMs to identify preventable factors. METHODS Multisource national data surveillance system study using an expert panel evaluating CCM AEs related to medication errors. INCLUSION CRITERIA age <12 years, and at least 1 significant AE from at least 1 index ingredient from a CCM OTC product. RESULTS From 2009 through 2016, 4756 cases were determined to have a significant AE related to an OTC CCM ingredient and 513 (10.8%) cases were due to a medication error. Nearly half of medication errors involved children 2 to <6 years old (n = 235; 45.8%). Many involved administration by a parent (n = 231; 45.0%) or alternative caregiver (n = 148; 28.8%). In nearly all cases (93.2%), the medication error involved the wrong dose of the medication. Health care facility evaluation occurred in 381 (74.3%) cases. Diphenhydramine and dextromethorphan were responsible for most medication errors and medication errors involving health care facility evaluation. There were no deaths from medication errors. CONCLUSION In this multiyear surveillance study, medication errors most commonly occurred in children <6 years old who received the wrong volume of a liquid product. Diphenhydramine and dextromethorphan dosing errors were the most common cause of medication errors resulting from CCM use. Continued standardization of measuring devices, concentrations, and units of measure along with consumer education are needed to further decrease medication errors from CCMs.
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Affiliation(s)
- George Sam Wang
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus (GS Wang), Aurora, Colo; Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority (GS Wang, KM Reynolds, RB Palmer, M Rapp-Olsson, JL Green, and RC Dart), Denver, Colo
| | - Kate M Reynolds
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority (GS Wang, KM Reynolds, RB Palmer, M Rapp-Olsson, JL Green, and RC Dart), Denver, Colo.
| | - William Banner
- Oklahoma Center for Poison and Drug Information, Oklahoma University College of Pharmacy (W Banner), Oklahoma City, Okla
| | - G Randall Bond
- Faculté de Médecine, Hope Africa University (GR Bond), Bujumbura, Burundi
| | - Ralph E Kauffman
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine (RE Kauffman), Kansas City, Mo
| | - Robert B Palmer
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority (GS Wang, KM Reynolds, RB Palmer, M Rapp-Olsson, JL Green, and RC Dart), Denver, Colo
| | - Ian M Paul
- Pediatrics & Public Health Sciences, Penn State College of Medicine (IM Paul), Hershey, Pa
| | - Malin Rapp-Olsson
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority (GS Wang, KM Reynolds, RB Palmer, M Rapp-Olsson, JL Green, and RC Dart), Denver, Colo
| | - Jody L Green
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority (GS Wang, KM Reynolds, RB Palmer, M Rapp-Olsson, JL Green, and RC Dart), Denver, Colo; Inflexion, an IBH Company (JL Green), Costa Mesa, Calif
| | - Richard C Dart
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority (GS Wang, KM Reynolds, RB Palmer, M Rapp-Olsson, JL Green, and RC Dart), Denver, Colo
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Graham J, Leonard J, Banerji S, Wang GS. Illicit Drug Exposures in Young Pediatric Patients Reported to the National Poison Data System, 2006-2016. J Pediatr 2020; 219:254-258.e1. [PMID: 31952846 DOI: 10.1016/j.jpeds.2019.11.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 10/11/2019] [Accepted: 11/05/2019] [Indexed: 02/08/2023]
Abstract
This retrospective review of poison center calls found that there were 9122 illicit drug exposures reported in children <10 years of age between 2006 and 2016. Marijuana and methamphetamine were reported most frequently, with significant increases over the study period; methamphetamine was associated with the most deaths.
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Affiliation(s)
| | | | - Shireen Banerji
- University of Colorado Denver, Aurora, CO; Rocky Mountain Poison and Drug Center, Denver, CO
| | - George Sam Wang
- University of Colorado Denver, Aurora, CO; Rocky Mountain Poison and Drug Center, Denver, CO
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32
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Wang GS, Xu L, Chen HT, Shi LP, Huang MJ, Xi L, Xu LS, Wang F, Li HY, Li S, Zhang YJ, Tan SY, Hong RT, Lyu NH, Ye M, Gan HT, Liu M, Wu BY. [Treatment of postprandial discomfort syndrome in the elderly: a multi-centered prospective randomized controlled clinical study]. Zhonghua Nei Ke Za Zhi 2020; 59:117-123. [PMID: 32074684 DOI: 10.3760/cma.j.issn.0578-1426.2020.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Objective: To evaluate the efficacy and safety of Oryz-Aspergillus enzyme and pancreatin tablets (Combizym(®)) in the treatment of postprandial distress syndrome (PDS) in the elderly, compared with gastrointestinal motility drugs. Methods: A prospective randomized controlled trial was designed and registered in the China Clinical Trials Registry (ChiCTR-IPR-16008185). The elderly patients with PDS were randomly divided into three groups, including Mosapride group with Mosapride citrate tablets 5 mg 3 times per day for 2 weeks; Combizym(®) group with Combizym tablets 244 mg 3 times per day for 2 weeks; combined treatment group with both drugs and same doses for 2 weeks. The modified Nepean dyspepsia index (NDSI) score, discomfort intensity score and PDS score were calculated on patients before treatment, at the end of first and second week of treatment, as well as 4 weeks after treatment finished, respectively. Adverse effects were evaluated. Results: A total of 323 patients from 16 tertiary hospitals in China were enrolled in this study. Among them, 105 patients were in Mosapride group, 109 in Combizym(®) group and 109 in combined treatment group. There were 148 males (45.8%) and 175 females (54.2%) with median age 71.4±9.0 years (60-100 years). Baseline characteristics of three groups were comparable. After treatment, the NDSI scores in three groups all decreased significantly (P<0.001), while they were similar between groups (P>0.05). The discomfort intensity score and PDS score in three groups showed a significant reduction after treatment (P<0.001), especially in the combined treatment group. Compared with Mosapride group, the scores in Combizym(®) group decreased significantly after one or two weeks [discomfort intensity score: after one week, 4.0(2.5, 8.0) vs. 6.0(3.0, 10.0); after two weeks, 3.0(0.0, 5.0) vs. 4.0(2.0, 6.0); all P<0.05. PDS score: after one week, 6.0(3.0, 9.0) vs. 7.0(3.5, 10.5); after two weeks, 3.0(0.0, 5.0) vs. 4.0(2.0, 7.0); all P<0.05]. The efficacy rate in all patients after first week of treatment was over 15.0%. The efficacy rates after two weeks were 55.2%, 68.8% and 73.4% in Mosapride group, Combizym(®) group and combined treatment group, respectively. After two week treatment, the efficacy rates in Combizym(®) group (P=0.041) and combined group (P=0.006) were higher than that of Mosapride group. The recurrence rate of Mosapride group was 9.5%, which was significantly higher than that of Combizym(®) group (1.8%, P<0.05) and combined treatment group (1.8%, P<0.05). There were no serious adverse effects in the three groups. Conclusions: The efficacy of Oryz-Aspergillus enzyme and pancreatin tablets is comparable with that of Mosapride in elderly PDS patients, with fewer adverse effects and low recurrence rate. Combination regimen indicates better efficacy than that of Oryz-Aspergillus enzyme and pancreatin tablets or Mosapride alone.
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Affiliation(s)
- G S Wang
- Department of Gastroenterology, The Second Medical Center of PLA General Hospital, Beijing 100853, China
| | - L Xu
- Department of Gastroenterology, Beijing Hospital, Beijing 100730, China
| | - H T Chen
- Department of Gastroenterology, The First Affiliated Hospital of Zhejiang University, Hangzhou 310003, China
| | - L P Shi
- Department of Geriatric Gastroenterology, Shaanxi Provincal People's Hospital, Xi'an 710068, China
| | - M J Huang
- Department of Gastroenterology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
| | - L Xi
- Department of Geriatrics, The First Hospital of Shanxi Medical University, Taiyuan 030001, China
| | - L S Xu
- Department of Geriatrics, Guangdong Provincal People's Hospital, Guangzhou 510080, China
| | - F Wang
- Department of Gastroenterology, The Third Xiangya Hospital of Central South University, Changsha 410013, China
| | - H Y Li
- Department of Geriatrics, The Seventh Medical Center of PLA General Hospital, Beijing 100700, China
| | - S Li
- Department of Gastroenterology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Y J Zhang
- Department of Geriatric Gastroenterology, PLA Southern Theater General Hospital, Guangzhou 510010, China
| | - S Y Tan
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan 430060, China
| | - R T Hong
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Hefei 230022, China
| | - N H Lyu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang 330006, China
| | - M Ye
- Department of Gastroenterology, Zhongnan Hospital of Wuhan University, Wuhan 430071, China
| | - H T Gan
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - M Liu
- Department of Gastroenterology, The Second Medical Center of PLA General Hospital, Beijing 100853, China
| | - B Y Wu
- Department of Gastroenterology, The Second Medical Center of PLA General Hospital, Beijing 100853, China
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Wang GS, Banerji S, Contreras AE, Hall KE. Marijuana exposures in Colorado, reported to regional poison centre, 2000–2018. Inj Prev 2019; 26:184-186. [DOI: 10.1136/injuryprev-2019-043360] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 10/01/2019] [Accepted: 10/03/2019] [Indexed: 11/04/2022]
Abstract
The objective was to evaluate trends in marijuana exposures reported to the Colorado regional poison centre (RPC). Human exposures cases from the Colorado RPC obtained from 1 January 2000 through 31 December 2018 using generic marijuana exposure codes. There were 2221 marijuana exposures, with an increase in exposures by 11.2 cases per year (p<0.0001). Annual cases remained steady since 2014 (p=0.22), with a 19.4% increase in 2018 compared with 2017. Since 2014, the largest increase was in children age 0–8 years (p<0.0001). Edible marijuana exposures increased by 9.6 exposures per year from 2015 to 2018 (p=0.04). After observing an increase in Colorado RPC marijuana exposure cases in 2010 and 2014, annual exposures have been stable through 2017, with the first increase in legalised recreational sales era in 2018. There are specific concerns for the paediatric population and exposures involving edibles, as these cases continue to increase.
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Heard K, Monte AA, Wang GS. Another Perspective on Cannabis and Emergency Medicine in Colorado. West J Emerg Med 2019; 20:855-856. [PMID: 31738711 PMCID: PMC6860395 DOI: 10.5811/westjem.2019.8.44882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 08/07/2019] [Indexed: 11/11/2022] Open
Affiliation(s)
- Kennon Heard
- University of Colorado School of Medicine, Department of Emergency Medicine, Section of Medical Pharmacology and Toxicology, Aurora, Colorado.,Rocky Mountain Poison and Drug Center, Denver, Colorado
| | - Andrew A Monte
- University of Colorado School of Medicine, Department of Emergency Medicine, Section of Medical Pharmacology and Toxicology, Aurora, Colorado.,Rocky Mountain Poison and Drug Center, Denver, Colorado
| | - George Sam Wang
- University of Colorado School of Medicine, Department of Emergency Medicine, Section of Medical Pharmacology and Toxicology, Aurora, Colorado.,Rocky Mountain Poison and Drug Center, Denver, Colorado.,University of Colorado School of Medicine, Department of Pediatrics, Section of Pediatric Emergency Medicine, Aurora, Colorado
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Ng PC, Banerji S, Graham J, Leonard J, Wang GS. Adolescent exposures to traditional and novel psychoactive drugs, reported to National Poison Data System (NPDS), 2007-2017. Drug Alcohol Depend 2019; 202:1-5. [PMID: 31279256 DOI: 10.1016/j.drugalcdep.2019.04.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 04/24/2019] [Accepted: 04/25/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Survey data on adolescent drug use trends have limitations evaluating the impact of drug use on health and may lag current trends. The objective was to describe National Poison Data System (NPDS) trends, medical outcomes, and healthcare encounters from adolescent exposures of traditional and novel psychoactive drugs. METHODS Retrospective review of adolescent (10-18 years of age) exposure calls to all U.S. poison centers, from January 1, 2007 through December 31, 2017, using generic codes for traditional and novel psychoactive drugs. Descriptive statistics and univariate Poisson regression modeling were used for analysis. RESULTS There were 49,757 exposure calls for the included psychoactive drugs. The median age was 16 years (IQR 15,17), 64% were male, and the majority were evaluated in a healthcare facility (92%). Marijuana had the most exposure calls (36.6%), followed by synthetic cannabinoids (e.g., spice; 21.3%). There were 181 (<1%) deaths; the highest fatality rates were from fentanyl, 2C drugs (phenylethylamine derivatives), and heroin. LSD exposure calls have had the most significant increase over the past 10 years. CONCLUSION U.S. Poison Centers reported almost 50,000 exposure calls and 181 deaths over 10 years for adolescent exposures of both traditional and novel psychoactive drugs, demonstrating the significant health impact on this vulnerable population. Opioids and 2C drugs contributed to the highest mortality rates, moderate/major symptoms and healthcare utilization, and LSD had the most significant increase in calls. Multi-source surveillance methodology is critical in understanding the public health impact on drug abuse in the adolescent population.
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Affiliation(s)
- Patrick C Ng
- Rocky Mountain Poison and Drug Center, Denver Health Hospital, Denver, CO, 80204, USA.
| | - Shireen Banerji
- Rocky Mountain Poison and Drug Center, Denver Health Hospital, Denver, CO, 80204, USA
| | - Jessica Graham
- Section of Emergency Medicine, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, 80045, USA
| | - Jan Leonard
- Section of Emergency Medicine, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, 80045, USA
| | - George Sam Wang
- Rocky Mountain Poison and Drug Center, Denver Health Hospital, Denver, CO, 80204, USA; Section of Emergency Medicine, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, 80045, USA
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Wang GS, Bourne DWA, Klawitter J, Sempio C, Chapman K, Knupp K, Wempe MF, Borgelt L, Christians U, Heard K, Bajaj L. Disposition of oral delta-9 tetrahydrocannabinol (THC) in children receiving cannabis extracts for epilepsy. Clin Toxicol (Phila) 2019; 58:124-128. [DOI: 10.1080/15563650.2019.1616093] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- George Sam Wang
- Section of Emergency Medicine and Medical Toxicology, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children’s Hospital Colorado, Aurora, CO, USA
| | - David W A Bourne
- Department of Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Center for Translational Pharmacokinetics and Pharmacogenomics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jost Klawitter
- iC42 Clinical Research and Development, Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Cristina Sempio
- iC42 Clinical Research and Development, Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Kevin Chapman
- Department of Neurology and Pediatrics, University of Colorado Anschutz Medical Campus, Children’s Hospital Colorado, Aurora, CO, USA
| | - Kelly Knupp
- Department of Neurology and Pediatrics, University of Colorado Anschutz Medical Campus, Children’s Hospital Colorado, Aurora, CO, USA
| | - Michael F. Wempe
- Departments of Clinical Pharmacy and Family Medicine, Skaggs School of Pharmacy and Pharmaceutical Sciences University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Laura Borgelt
- Departments of Clinical Pharmacy and Family Medicine, Skaggs School of Pharmacy and Pharmaceutical Sciences University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Uwe Christians
- iC42 Clinical Research and Development, Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Kennon Heard
- Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, University of Colorado Hospital, Aurora, CO, USA
| | - Lalit Bajaj
- Section of Emergency Medicine and Medical Toxicology, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children’s Hospital Colorado, Aurora, CO, USA
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Wang GS, Dong M, Sheng WW, Zhou JP. [Preoperative restricted versus liberal fluid administration on perioperative safety for pancreatic surgery: a Meta-analysis]. Zhonghua Wai Ke Za Zhi 2019; 55:618-625. [PMID: 28789514 DOI: 10.3760/cma.j.issn.0529-5815.2017.08.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Objective: To assess the perioperative safety of preoperative restricted fluid administration and liberal fluid administration for pancreatic surgery. Methods: The randomized controlled trials comparing restricted and liberal in pancreatic surgery were collected by searching the databases of PubMed, Embase and the Cochrane Library.Two reviewers independently selected studies according to the inclusion and exclusion criteria, then extracted the data and assessed the quality of included studies.Meta-analysis was performed by RevMan 5.3 software. Results: A total of 4 studies involving 785 patients were finally included, with 396 cases in restricted group and 389 cases in liberal group.Results of Meta-analysis showed that there was no statistically significant difference between the two groups in terms of intraoperative blood loss, postoperative complications, mortality, reoperation in-hospital and length of stay(all P>0.05). Conclusion: With regard to pancreatic surgery, restricted fluid administration do not have outstanding advantages.
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Affiliation(s)
- G S Wang
- Department of Gastrointestinal Surgery and Hernia and Abdominal Wall Surgery, the First Hospital, China Medical University, Shenyang 110001, China
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Wang GS, Haynes C, Besharat A, Lait MCL, Green JL, Dart RC, Roosevelt G. Brief report: Characterization of marijuana use in us college students by state marijuana legalization status as reported to an online survey. Am J Addict 2019; 28:266-269. [PMID: 30901123 DOI: 10.1111/ajad.12870] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 02/07/2019] [Accepted: 02/10/2019] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND AND OBJECTIVE US college student marijuana use is the highest since 1980. The objective was to investigate use characteristics among college students. METHODS The RADARS® System College Survey Program surveyed individuals in a university, technical or online school. This was a secondary analysis of existing data. RESULTS Seven thousand one hundred five students were enrolled, <30% of students' perceived marijuana use a health risk. Students in medical states were more likely to use marijuana compared to non-legal states. (p < .001) Smoking and edibles were common methods of use. CONCLUSIONS Higher reports of college student use were observed in medical states without differences in risk perception. SCIENTIFIC SIGNIFICANCE This study further demonstrates the public health impact of marijuana legalization by comparing college study use of marijuana by state legalization status, and demonstrating high rates of use of concentrated products. These findings should be factored when determining regulations and preventative measures when legalizing marijuana. (Am J Addict 2019;28:266-269).
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Affiliation(s)
- George Sam Wang
- University of Colorado Anschutz Medical Campus, Department of Pediatrics, Children's Hospital Colorado, Aurora, Colorado
- Rocky Mountain Poison and Drug Center, Denver Health Hospital, Denver, Colorado
| | - Colleen Haynes
- Rocky Mountain Poison and Drug Center, Denver Health Hospital, Denver, Colorado
| | - Andrea Besharat
- Rocky Mountain Poison and Drug Center, Denver Health Hospital, Denver, Colorado
| | | | - Jody L Green
- Inflexxion, an IBH Company, Costa Mesa, California
| | - Richard C Dart
- Rocky Mountain Poison and Drug Center, Denver Health Hospital, Denver, Colorado
| | - Genie Roosevelt
- Department of Emergency Medicine, Denver Health Hospital, Denver, Colorado
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Chu H, Fang X, Tan Z, Zhen X, Wu RL, Li XP, Wang GS, Wang YP, Li XM. [Correlation between the changes of innate lymphoid cells in peripheral blood of systemic lupus erythematosus and its clinical significance]. Zhonghua Yi Xue Za Zhi 2019; 99:169-173. [PMID: 30669757 DOI: 10.3760/cma.j.issn.0376-2491.2019.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Objective: To explore the function and role of innate lymphoid cells in the pathogenesis of systemic lupus erythematosus (SLE) at different disease activity levels. Methods: From Nov 2017 to May 2018, 40 patients with SLE and 15 age-matched healthy non-immune-related diseases controls were enrolled from Anhui provincial hospital. According to the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI)-2K, the patients were divided into active group (n=20) and remission group (n=20). The frequency of ILCs, B cells, CD4+T and CD8+T cells from peripheral blood mononuclear cells (PBMCs) was detected by flow cytometry. The subsets of ILCs in each group were compared with the subsets of B cells and T cell respectively. The levels of IL-4, IL-33 and IFN-γ in each group were tested by ELISA. Result: Compared with the control group, ILC1 percentage was significantly increased in SLE active group [(22.33%±2.52%) vs (14.56%±1.28%), P=0.018 1]; ILC2 percentage was decreased significantly in both remission group [(19.67%±1.83%) vs (42.48%±3.46%), P<0.000 1] and active group [(8.67%±0.83%) vs (19.67%±1.83%), P<0.000 1]; ILC3 percentage was decreased significantly in active group [(5.72%±1.08%) vs (14.35%±2.40%), P=0.001 3]. SLEDAI score was negatively correlated with the percentage of ILC2 (P=0.023 9) in all patients. The percentage of ILCs in the remission group (P=0.046 2) and activity group (P=0.003 7) were both increased significantly. Moreover, the percentage of ILC2 in active group was negatively correlated with CD4+T cells (P=0.030 8), and the serum IgG was negatively correlated with ILC2% in all patients (P=0.013 8). Compared with control group or remission group, the levels of IFN-γ (F=10.91, P=0.000 1) and IL-4 (F=6.046, P=0.004 7) in active group were remarkable higher. However, IL-33 was significantly reduced in active group (F=6.645, P=0.002 7). The percentage of ILC2 (r=0.154 3, P=0.028 8) and ILC3 (r=0.313 6, P=0.001 1) in all patients with SLE were positively correlated with the level of IL-4. Conclusion: The percentage of ILCs is related to disease activity, and ILCs play a "double-edged" role in the pathogenesis of SLE. Its function and mechanism are worth further exploration.
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Affiliation(s)
- H Chu
- Department of Rheumatology and Immunology, Anhui Provincial Hospital affiliated with Anhui Medical University, Hefei 230001, China
| | - X Fang
- Department of Rheumatology and Immunology, Anhui Provincial Hospital affiliated with Anhui Medical University, Hefei 230001, China
| | - Z Tan
- Department of Rheumatology and Immunology, Anhui Provincial Hospital affiliated with Anhui Medical University, Hefei 230001, China
| | - X Zhen
- Department of Rheumatology and Immunology, Anhui Provincial Hospital affiliated with Anhui Medical University, Hefei 230001, China
| | - R L Wu
- Department of Rheumatology and Immunology, Anhui Provincial Hospital affiliated with Anhui Medical University, Hefei 230001, China
| | - X P Li
- Department of Rheumatology and Immunology, Anhui Provincial Hospital affiliated with Anhui Medical University, Hefei 230001, China
| | - G S Wang
- Department of Rheumatology and Immunology, Anhui Provincial Hospital affiliated with Anhui Medical University, Hefei 230001, China
| | - Y P Wang
- Centre for Transplantation and Renal Research, Westmead Insitute for Medical Research, the University of Sydney, Westmead 2145 NSW, Australia
| | - X M Li
- Department of Rheumatology and Immunology, Anhui Provincial Hospital affiliated with Anhui Medical University, Hefei 230001, China
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Ng PC, Schimmel J, Wang GS. Lacosamide Overdose: A Case of QRS Prolongation and Seizure. J Emerg Med 2019; 56:652-656. [PMID: 30879851 DOI: 10.1016/j.jemermed.2019.01.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 01/04/2019] [Accepted: 01/17/2019] [Indexed: 01/21/2023]
Abstract
BACKGROUND Lacosamide is a third-generation antiepileptic drug. Its likely mechanism of action is via neuronal sodium channel blockade, via a unique manner compared with other antiepileptic drugs that block sodium channels. A paucity of information exists regarding lacosamide overdosage. Lacosamide overdosage is thought to cause QRS prolongation and seizures, due to its effect of sodium channel blockade. The potential efficacy of sodium bicarbonate to reverse the effects of lacosamide has not been well studied. Furthermore, prior reports of lacosamide toxicity have occurred in the setting of concomitant polypharmacy. Thus, the isolated toxic effects of the drug have not been well elucidated. CASE REPORT We report a case of a suspected, single-ingestion overdose on lacosamide. The patient developed signs of cardiotoxicity and seizure. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: After lacosamide overdosage, the emergency physician must be capable of acute management of subsequent lacosamide toxicity. Understanding the mechanisms of action causing toxicity due to this drug can help the clinician to anticipate the interventions that may be needed or useful to treat this potentially toxic ingestion.
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Affiliation(s)
- Patrick C Ng
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, Denver, Colorado; Department of Emergency Medicine, University of Colorado at Denver-Anschutz Medical Campus, Aurora, Colorado
| | - Jonathan Schimmel
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, Denver, Colorado
| | - George Sam Wang
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, Denver, Colorado; Department of Pediatrics, Children's Hospital Colorado, Aurora, Colorado
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Tang H, Ding F, Yao J, Xu C, Zhang J, Wang GS, Yi SH, Li H, Yang Y, Chen GH. [Liver transplantation for polycystic liver disease: 11 cases report and literature review]. Zhonghua Yi Xue Za Zhi 2019; 99:767-770. [PMID: 30884632 DOI: 10.3760/cma.j.issn.0376-2491.2019.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Objective: To explore the indications and safety of orthopedic liver transplantation for polycystic liver disease (PLD). Methods: Data of 11 patients with PLD who underwent orthotopic liver transplantation between 2004 and 2013 was retrospectively analyzed. Demographic, clinical and follow-up data were collected for statistical analysis. The survival rate was calculated by Kaplan-Meier method. Results: Over a period of 10 years, the patients received modified piggyback orthopedic liver transplantation (n=9) or combined liver-kidney transplantation (n=2) for PLD. The recipients' median age was 56 years. Seven patients were classified as Gigot type Ⅱ PLD, and four were classified as Gigot type Ⅲ PLD. Eight patients had severe decreased mobility (Eastern Cooperative Oncology Group, ECOG≥3). Only three cases were Child-Pguh Class C patients and the model for end-stage liver disease (MELD) score was>20. The mean hospitalization duration was (45.4±15.3) days, and the mean length of stay in intensive care unit was (4.1±1.9) days. The perioperative mortality was 18.2% and morbidity of complications was 63.6%. The median follow-up period was 111 months. Two patients died of severe complications after combined liver-kidney transplantation. One patient died of ischemia cholangitis during follow-up. The actuarial 1-, 5-and 10-year survival rate during the follow-up period was 82.2%, 81.8%, and 65.5%, respectively. Conclusions: Liver transplantation is the only curative and safe procedure for PLD, and it provides a good long-term prognosis and high quality of life for PLD patients. Liver transplantation could be a primary option in treating progressive or advanced PLD.
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Affiliation(s)
- H Tang
- Liver Transplantation Center, the Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
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Abstract
Novel drugs of abuse are synthetic illicit drugs, or analogues of known illicit drugs, that can be more potent. Novel drugs of abuse are often labeled as designer drugs, research chemicals, legal highs, or psychoactive substances. They are often sold as designated legal or nondrug products, such as incense, plant food, or bath salts, with labeling such as "Not for Human Consumption" or "For Use in Research Only." The prevalence of use of novel drugs of abuse is difficult to determine because specific drugs, compounds, and availability of these drugs are constantly evolving. Changes in chemical structures lead to heterogeneity in physiologic response and clinical symptoms, even within the same category of drug. Pediatricians and emergency medicine physicians should be knowledgeable about novel drugs of abuse and their resulting symptoms for prevention and identification of their use.
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Affiliation(s)
- George Sam Wang
- Section of Emergency Medicine and Medical Toxicology, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO.,Rocky Mountain Poison and Drug Center, Denver Health Hospital, Denver, CO
| | - Christopher Hoyte
- Rocky Mountain Poison and Drug Center, Denver Health Hospital, Denver, CO.,Department of Emergency Medicine and Medical Toxicology, University of Colorado Anschutz Medical Campus, University Hospital, Aurora, CO
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Affiliation(s)
- George Sam Wang
- 1 University of Colorado Anschutz Medical Campus, Aurora, CO, USA.,2 Children's Hospital Colorado, Aurora, CO, USA
| | - Christopher Hoyte
- 1 University of Colorado Anschutz Medical Campus, Aurora, CO, USA.,3 University of Colorado Hospital, Aurora, CO, USA.,4 Rocky Mountain Poison and Drug Center, Denver, CO, USA
| | | | - Kennon Heard
- 1 University of Colorado Anschutz Medical Campus, Aurora, CO, USA.,3 University of Colorado Hospital, Aurora, CO, USA
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Affiliation(s)
- George Sam Wang
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA; Section of Emergency Medicine, USA; Children's Hospital Colorado, Aurora, Colorado, USA.
| | - Sara Deakyne Davies
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA; Section of Emergency Medicine, USA; Children's Hospital Colorado, Aurora, Colorado, USA; Research Informatics, USA
| | - Laurie Seidel Halmo
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA; Children's Hospital Colorado, Aurora, Colorado, USA
| | - Amy Sass
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA; Children's Hospital Colorado, Aurora, Colorado, USA; Section of Adolescent Medicine, USA
| | - Rakesh D Mistry
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA; Section of Emergency Medicine, USA; Children's Hospital Colorado, Aurora, Colorado, USA
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Abstract
In the 1920s, guanidine, the active component of Galega officinalis, was shown to lower glucose levels and used to synthesize several antidiabetic compounds. Metformin (1,1 dimethylbiguanide) is the most well-known and currently the only marketed biguanide in the United States, United Kingdom, Canada, and Australia for the treatment of non-insulin-dependent diabetes mellitus. Although phenformin was removed from the US market in the 1970s, it is still available around the world and can be found in unregulated herbal supplements. Adverse events associated with therapeutic use of biguanides include gastrointestinal upset, vitamin B12 deficiency, and hemolytic anemia. Although the incidence is low, metformin toxicity can lead to hyperlactatemia and metabolic acidosis. Since metformin is predominantly eliminated from the body by the kidneys, toxicity can occur when metformin accumulates due to poor clearance from renal insufficiency or in the overdose setting. The dominant source of metabolic acidosis associated with hyperlactatemia in metformin toxicity is the rapid cytosolic adenosine triphosphate (ATP) turnover when complex I is inhibited and oxidative phosphorylation cannot adequately recycle the vast quantity of H+ from ATP hydrolysis. Although metabolic acidosis and hyperlactatemia are markers of metformin toxicity, the degree of hyperlactatemia and severity of acidemia have not been shown to be of prognostic value. Regardless of the etiology of toxicity, treatment should include supportive care and consideration for adjunct therapies such as gastrointestinal decontamination, glucose and insulin, alkalinization, extracorporeal techniques to reduce metformin body burden, and metabolic rescue.
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Affiliation(s)
- George Sam Wang
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA.,Children's Hospital Colorado, Aurora, CO, USA
| | - Christopher Hoyte
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA.,University of Colorado Hospital, Aurora, CO, USA
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Liu Q, Wang D, Yuan M, He BF, Li J, Mao C, Wang GS, Qian H. Capturing intracellular oncogenic microRNAs with self-assembled DNA nanostructures for microRNA-based cancer therapy. Chem Sci 2018; 9:7562-7568. [PMID: 30319757 PMCID: PMC6180306 DOI: 10.1039/c8sc03039a] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 08/07/2018] [Indexed: 01/06/2023] Open
Abstract
Aberrantly overexpressed oncogenic microRNAs (miRNAs, miRs) are excellent targets for therapeutic interventions.
Aberrantly overexpressed oncogenic microRNAs (miRNAs, miRs) are excellent targets for therapeutic interventions. Nevertheless, thus far, little progress has been made in developing miRNA-based drugs and techniques for clinical applications, especially for overexpressed miRNAs. In this study, we demonstrate that self-assembled DNA nanostructures bearing multiple DNA sequences that are complementary to a target miRNA can effectively capture the overexpressed oncogenic miRNA and subsequently inhibit cancer cell proliferation. Specifically, a DNA nanotube structure that carries functional DNA segments (single-stranded, duplex and hairpin forms) was designed and synthesized to capture two well-known overexpressed miRNAs, miR-21 and miR-155. It was found that all three DNA nanotubes significantly reduced both miRNA levels and inhibited cancer cell growth. Moreover, the capture efficiency was highly concentration dependent and was associated with the structural design of the DNA nanotube. These results demonstrate that through careful design, programmable DNA nanostructures can hijack the natural cellular machinery and can serve as nucleic acid drugs themselves. The concept of using self-assembled DNA nanostructures to disrupt the intracellular machinery for therapeutic purposes opens a new paradigm for exploiting self-assembled DNA nanostructures for miRNA-based anticancer therapy.
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Affiliation(s)
- Q Liu
- Institute of Respiratory Diseases , Xinqiao Hospital , Third Military Medical University , Chongqing 400037 , China . ; ; ; Tel: +86 23 68755644
| | - D Wang
- Institute of Respiratory Diseases , Xinqiao Hospital , Third Military Medical University , Chongqing 400037 , China . ; ; ; Tel: +86 23 68755644
| | - M Yuan
- Institute of Respiratory Diseases , Xinqiao Hospital , Third Military Medical University , Chongqing 400037 , China . ; ; ; Tel: +86 23 68755644
| | - B F He
- Institute of Respiratory Diseases , Xinqiao Hospital , Third Military Medical University , Chongqing 400037 , China . ; ; ; Tel: +86 23 68755644
| | - J Li
- Institute of Respiratory Diseases , Xinqiao Hospital , Third Military Medical University , Chongqing 400037 , China . ; ; ; Tel: +86 23 68755644
| | - C Mao
- Department of Chemistry , Purdue University , West Lafayette , IN 47907 , USA
| | - G S Wang
- Institute of Respiratory Diseases , Xinqiao Hospital , Third Military Medical University , Chongqing 400037 , China . ; ; ; Tel: +86 23 68755644
| | - H Qian
- Institute of Respiratory Diseases , Xinqiao Hospital , Third Military Medical University , Chongqing 400037 , China . ; ; ; Tel: +86 23 68755644
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Wang GS, Davies SD, Halmo LS, Sass A, Mistry RD. Impact of Marijuana Legalization in Colorado on Adolescent Emergency and Urgent Care Visits. J Adolesc Health 2018; 63:239-241. [PMID: 29609916 DOI: 10.1016/j.jadohealth.2017.12.010] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 12/18/2017] [Accepted: 12/19/2017] [Indexed: 11/19/2022]
Abstract
PURPOSE Approximately 6%-8% of U.S. adolescents are daily/past-month users of marijuana. However, survey data may not reliably reflect the impact of legalization on adolescents. The objective was to evaluate the impact of marijuana legalization on adolescent emergency department and urgent cares visits to a children's hospital in Colorado, a state that has allowed both medical and recreational marijuana. METHODS Retrospective review of marijuana-related visits by International Classification of Diseases codes and urine drug screens, from 2005 through 2015, for patients ≥ 13 and < 21 years old. RESULTS From 2005 to 2015, 4,202 marijuana-related visits were identified. Behavioral health evaluation was obtained for 2,813 (67%); a psychiatric diagnosis was made for the majority (71%) of these visits. Coingestants were common; the most common was ethanol (12%). Marijuana-related visits increased from 1.8 per 1,000 visits in 2009 to 4.9 in 2015. (p = < .0001) CONCLUSIONS: Despite national survey data suggesting no appreciable difference in adolescent marijuana use, our data demonstrate a significant increase in adolescent marijuana-associated emergency department and urgent cares visits in Colorado.
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Affiliation(s)
- George Sam Wang
- University of Colorado Anschutz Medical Campus, Aurora, Colorado; Section of Emergency Medicine, Children's Hospital Colorado, Aurora, Colorado; Department of Pediatrics, Children's Hospital Colorado, Aurora, Colorado.
| | - Sara Deakyne Davies
- University of Colorado Anschutz Medical Campus, Aurora, Colorado; Research Informatics, Children's Hospital Colorado, Aurora, Colorado; Department of Pediatrics, Children's Hospital Colorado, Aurora, Colorado
| | - Laurie Seidel Halmo
- University of Colorado Anschutz Medical Campus, Aurora, Colorado; Department of Pediatrics, Children's Hospital Colorado, Aurora, Colorado
| | - Amy Sass
- University of Colorado Anschutz Medical Campus, Aurora, Colorado; Section of Adolescent Medicine, Children's Hospital Colorado, Aurora, Colorado; Department of Pediatrics, Children's Hospital Colorado, Aurora, Colorado
| | - Rakesh D Mistry
- University of Colorado Anschutz Medical Campus, Aurora, Colorado; Section of Emergency Medicine, Children's Hospital Colorado, Aurora, Colorado; Department of Pediatrics, Children's Hospital Colorado, Aurora, Colorado
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Abstract
Adolescent substance abuse remains common, with almost a third of adolescents admitting to ethanol use, and a quarter admitting to illicit drug use. It is essential for pediatricians to regularly screen adolescent patients for substance use, because early initiation of drug use has been associated with physical, behavioral, and social health risks. Adolescents abuse what is common and readily available; this includes ethanol, over-the-counter products, marijuana, and inhalants. The most common and effective clinical treatments for significant toxicity from substances of abuse is symptomatic and supportive care including hemodynamic support, respiratory support, and sedation to control psychomotor agitation.
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Affiliation(s)
- George Sam Wang
- Section of Emergency Medicine and Medical Toxicology, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO.,Rocky Mountain Poison and Drug Center, Denver Health Hospital, Denver, CO
| | - Christopher Hoyte
- Rocky Mountain Poison and Drug Center, Denver Health Hospital, Denver, CO.,Department of Emergency Medicine and Medical Toxicology, University of Colorado Anschutz Medical Campus, University Hospital, Aurora, CO
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Wang GS, Liu K, Wang SL. Evolution of Elevated-Temperature Strength and Creep Resistance during Multi-Step Heat Treatments in Al-Mn-Mg Alloy. Materials (Basel) 2018; 11:ma11071158. [PMID: 29986489 PMCID: PMC6073777 DOI: 10.3390/ma11071158] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 07/02/2018] [Accepted: 07/03/2018] [Indexed: 11/20/2022]
Abstract
The present work has systematically investigated the evolution of dispersoids and elevated-temperature properties including strength and creep resistance during various multi-step heat treatments in Al-Mn-Mg 3004 alloys. Results show that only the α-Al(MnFe)Si dispersoid is observed in the studied temperature range (up to 625 °C), and that it coarsens with increasing temperature to 500 °C, but dissolves at 625 °C. The evolution of elevated-temperature strength and creep resistance is greatly related to the temperature of each step during the multi-step heat treatments. Generally, lower temperature at the first-step heat treatment leads to higher properties, while the properties decrease with increasing temperature of last-step heat treatment. Suitable models have been introduced to explain the evolution of strength and the creep threshold stress at elevated-temperatures during the various heat treatments.
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Affiliation(s)
- G S Wang
- Key Laboratory of Electromagnetic Processing of Materials, Ministry of Education, Northeastern University, Shenyang 110819, China.
- School of Materials Science and Engineering, Northeastern University, Shenyang 110819, China.
| | - K Liu
- Department of Applied Science, University of Quebec at Chicoutimi, Saguenay, QC G7H 2B1, Canada.
| | - S L Wang
- Key Laboratory of Electromagnetic Processing of Materials, Ministry of Education, Northeastern University, Shenyang 110819, China.
- School of Materials Science and Engineering, Northeastern University, Shenyang 110819, China.
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Wang GS, Severtson SG, Bau GE, Dart RC, Green JL. Unit-Dose Packaging and Unintentional Buprenorphine-Naloxone Exposures. Pediatrics 2018; 141:peds.2017-4232. [PMID: 29724879 DOI: 10.1542/peds.2017-4232] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/09/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Buprenorphine accounts for the most opioid-related pediatric hospital admissions when compared with other opioid analgesics. Since 2010, several manufacturers began distributing their buprenorphine products with unit-dose packaging (UDP). Our main objective in this study is to evaluate the impact of UDP on unintentional pediatric buprenorphine-naloxone poison center exposures. METHODS This is an observational surveillance study in which the Researched Abuse, Diversion, and Addiction-Related Surveillance System Poison Center Program is used. The main outcome was cases of unintentional ingestions involving children <6 years old and buprenorphine-naloxone (combination) products. The study was split into 3 periods: pre-UDP (first quarter 2008 through fourth quarter 2010), transition to UDP (first quarter 2011 through fourth quarter 2012), and post-UDP (first quarter 2013 through fourth quarter 2016). RESULTS Overall, there were 6217 exposures to combination products. In the pre-UDP period, there were 20.57 pediatric unintentional exposures per 100 000 prescriptions dispensed; in the transition to UDP period, there were 8.77 pediatric unintentional exposures per 100 000 prescriptions dispensed; and in the post-UDP period, there were 4.36 pediatric unintentional exposures per 100 000 prescriptions dispensed. This represents a 78.8% (95% confidence interval: 76.1%-81.3%; P < .001) relative decrease from the pre-UDP period. CONCLUSIONS The shift from non-UDP to UDP in over 80% of buprenorphine-naloxone products was associated with a significant decrease in unintentional pediatric exposures reported to poison centers. Packaging controls should be a mainstay in the approach to the prevention of unintentional buprenorphine pediatric exposures as well as exposures to other prescription opioids.
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Affiliation(s)
- George Sam Wang
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, Colorado; .,Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, Denver, Colorado
| | - S Geoffrey Severtson
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, Denver, Colorado
| | - Gabrielle E Bau
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, Denver, Colorado
| | - Richard C Dart
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, Denver, Colorado.,Department of Emergency Medicine, School of Medicine, University of Colorado, Denver, Colorado; and
| | - Jody L Green
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, Denver, Colorado.,Inflexxion, Waltham, Massachusetts
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