Non-fatal overdose with a new synthetic opioid

A young man experienced respiratory arrest at home, and cardiopulmonary resuscitation was performed. The patient received naloxone with good effect and was admitted to hospital. He disclosed opioid use, but no substances were detected in routine drug screenings.

Lumbosacral transitional vertebra in 14 dog breeds in Norway: Occurrence, risk factors and association with hip dysplasia

A lumbosacral transitional vertebra (LTV) is a congenital anomaly of the spine and has been suggested to predispose to canine hip dysplasia (CHD). This retrospective, cross-sectional study investigated the prevalence of LTV and CHD among 14 dog breeds in Norway, the possible associations with risk factors, and whether LTV was a risk factor for the development of hip dysplasia. The results were based on evaluation of ventrodorsal radiographs from the CHD screening program from the Norwegian Kennel Club from February 2014 to January 2022. A total of 13,950 dogs were included in the study. For statistical analysis, CHD grades were reclassified from the official Federation Cynologique Internationale (FCI) grades into three grades: CHD free (CHD=A, B), CHD mild (CHD=C), and CHD severe (CHD=D, E). In the study sample, the overall occurrence of LTV was 18.5%, of which 32.9% were type 1, 45.7% type 2% and 21.4% type 3. The occurrence of LTV varied significantly among the included breeds, ranging from 9.5% to 46.2%. There was no association between sex and LTV. The frequencies of CHD grades were A: 43.1%; B: 31.4%; C: 18.4%; D: 6.0%; E: 1.1%. There was a statistically significant association with mild and severe CHD in dogs with LTV type 2 and LTV type 3 (P< 0.001). In the population studied, the prevalence of LTV was different among breeds. This supports initial data on the heredity of LTV and the diverse occurrence of LTV among breeds. Our results indicate that LTV type 2 and type 3 are associated with mild and severe CHD development. Therefore, this study has potentially identified an additional risk factor for the development of hip dysplasia.

Extended Detection Window for Gamma-Hydroxybutyrate in the Urine of an Elderly Woman

Gamma-hydroxybutyrate (GHB) is a central nervous system depressant that has gained popularity as an illicit recreational drug. We describe a case of an elderly woman who was found unconscious in her home. The paramedics initially suspected an intracranial incident. A head computed tomography (CT) was negative, as was the initial urinary drug screening. The diagnosis of GHB intoxication was made with detection of GHB in a urine sample obtained 28-29 hours after assumed time of intake. Our case underscores the importance of considering drug testing in a broad range of patients, and shows that elderly patients may have an extended detection window of GHB.

Oxazepam Detected in Urine 79 Days After Withdrawal of Diazepam: A Case Report

Patients suffering from substance use disorder, including for instance benzodiazepines, may have comorbidity with attention deficit hyperactivity disorder (ADHD). Centrally acting stimulants play an important role in the treatment of ADHD. Before such treatment can be initiated, withdrawal of benzodiazepines may be necessary. Urine testing is the preferred method for monitoring adherence in benzodiazepine withdrawal, but there is a lack of studies reporting detection time. Here, we report a case of a 30-year-old woman with substance use disorder and ADHD who had detectable metabolites of diazepam 79 days after withdrawal. To our knowledge, no cases with detection time equivalent to this have previously been published. This case report serves as an example that clinicians may need to consider interindividual pharmacokinetic characteristics when interpreting the results of urine drug tests, and that a positive urine test may still be consistent with abstinence from a certain drug. In the current case, a high body mass index and a genetic polymorphism gave a reasonable explanation for the prolonged detection of diazepam metabolites.

An apathetic child with hallucinations

BACKGROUND

Lysergic acid diethylamide (LSD) is a potent, hallucinogenic substance that distorts the perception, state of consciousness and behaviour of the user. LSD poisonings are rare in children and may be difficult to recognise based on clinical symptoms alone.

CASE PRESENTATION

A young boy was admitted to the hospital because of bizarre behaviour and reduced responsiveness towards his parents. At first, he was agitated. Later he fell silent and became apathetic. He suffered from ataxia and showed signs of visual hallucinations. A conclusive diagnosis of LSD poisoning was made possible through targeted and specific laboratory testing of blood and urine samples. The patient recovered completely without any specific treatment.

INTERPRETATION

We urge doctors who examine paediatric patients with acute and unexplained neuropsychiatric symptoms or abnormal behaviour to consider drug intoxication as a possible differential diagnosis. Blood and urine samples from such patients should be obtained as soon as possible and analysed for a broad spectrum of substances. No antidote exists for LSD. If sedation is required due to convulsions, tachycardia, agitation, or frightening hallucinations, treatment with a benzodiazepine, such as diazepam or midazolam, is recommended.

Should more patients be offered treatment with cannabinoids?

Today, a small but growing number of patients in Norway are prescribed cannabinoids for medical use. Despite the large focus on their potential as medicines, there is limited scientific knowledge about the positive effects, adverse effects, long-term effects and interaction potential of cannabinoids.

Reference ranges for antiepileptic drugs revisited: a practical approach to establish national guidelines

BACKGROUND AND OBJECTIVE

Laboratories sometimes use different reference ranges for the same antiepileptic drug (AED), particularly for new and poorly investigated drugs. This may contribute to misunderstandings, concerns or inappropriate dose changes, which in turn may affect therapeutic effect, drug safety or treatment adherence. Therefore, the Norwegian Association of Clinical Pharmacology wished to update and harmonize the reference ranges for AEDs and establish national guidelines for Norway.

METHODS

A working group collected information on the reference ranges used by Norwegian laboratories for all commonly used AEDs. These reference ranges were compared to recent recommendations by the International League Against Epilepsy, current literature, applicable clinical studies, reference ranges used by leading Northern European epilepsy centers outside of Norway, and routine data derived from Norwegian laboratory databases.

RESULTS

Reference ranges varied between laboratories for four of 23 available AEDs (lamotrigine, valproate, eslicarbazepine and oxcarbazepine). For four AEDs (brivaracetam, perampanel, stiripentol and sulthiame), reference ranges had not previously been established. In total, 13 reference ranges were either harmonized, updated or newly established. No changes were applied to the remaining 10 AEDs.

CONCLUSION

Updated and harmonized reference ranges are now available for 22 of the 23 AEDs available in Norway. The exception is vigabatrin (reference range not applicable). Revision of reference ranges is an important part of pharmacovigilance of AEDs and must be a continuous process based on current literature and clinical experience.

Cross-reactivity of the CEDIA buprenorphine assay in drugs-of-abuse screening: influence of dose and metabolites of opioids

PURPOSE

The cloned enzyme donor immunoassay (CEDIA) for buprenorphine is applied for both urine drugs-of-abuse screening and compliance monitoring. Sensitivity, specificity, and optimal cutoff of this assay have differed between studies. This may indicate that cross-reactivity has to be taken into account during assay evaluation. We therefore investigated the performance of the CEDIA buprenorphine assay for use in our patient population and explored the impact of cross-reactivity on assay accuracy.

METHODS

The CEDIA buprenorphine assay and high-performance liquid chromatography-tandem mass spectrometry were employed to analyze drugs-of-abuse in urine samples from a healthy drug-naïve male volunteer after intake of two tablets of a prescription drug containing 400 mg paracetamol +30 mg codeine phosphate, and in urine samples (n=2,272) from drug-addicted patients. Receiver operating characteristic analyses were performed to express the diagnostic accuracy of the CEDIA buprenorphine assay.

RESULTS

CEDIA buprenorphine was positive in one urine sample from the drug-naïve person after intake of the prescription drug. Twenty-five (1.1%) of the patient urine samples were positive for buprenorphine by CEDIA, but negative by high-performance liquid chromatography-tandem mass spectrometry. Codeine, morphine, and their respective metabolites were prevalent in samples that were false positive for buprenorphine. The specificity of the CEDIA buprenorphine assay increased to 99.7% when the cutoff was increased from 5 ng/mL to 10 ng/mL.

CONCLUSION

Intake of a therapeutic dose of codeine can yield a false-positive CEDIA buprenorphine result. Additive effects from metabolites of codeine contribute to cross-reactivity in concentrations much lower than listed in the manufacturer's cross-reactivity guide. Raising the cutoff from 5 ng/mL to 10 ng/mL increased the diagnostic accuracy. Clinicians should be informed about the risk of false-positive results with the CEDIA buprenorphine assay.

Behavioral demonstration of a somatosensory neuroprosthesis

Tactile sensation is critical for effective object manipulation, but current prosthetic upper limbs make no provision for delivering somesthetic feedback to the user. For individuals who require use of prosthetic limbs, this lack of feedback transforms a mundane task into one that requires extreme concentration and effort. Although vibrotactile motors and sensory substitution devices can be used to convey gross sensations, a direct neural interface is required to provide detailed and intuitive sensory feedback. In light of this, we describe the implementation of a somatosensory prosthesis with which we elicit, through intracortical microstimulation (ICMS), percepts whose magnitude is graded according to the force exerted on the prosthetic finger. Specifically, the prosthesis consists of a sensorized finger, the force output of which is converted into a regime of ICMS delivered to primary somatosensory cortex through chronically implanted multi-electrode arrays. We show that the performance of animals (Rhesus macaques) on a tactile task is equivalent whether stimuli are delivered to the native finger or to the prosthetic finger.

[High incidence of work-related disease among asthmatics on sick-leave]

BACKGROUND

We have previously shown that work-related asthma is substantially underreported and usually not notified to the Labour Inspection Authority until it has become chronic and interferes with future work. The aim of this study was to evaluate whether conditions relating to individuals are important for the susceptibility to work-related asthma and to assess whether there is a correspondence between patients' and physicians' perception of the importance of exposure to work in relation to the disease.

MATERIAL AND METHODS

Questionnaires were sent to 824 workers (56% women) aged 18-55 years, who had been on sick leave > 16 days in the years 2000-2003. The disease was classified as work-related asthma if the following questions were answered positively: "Have you ever had respiratory symptoms in relation to your work?" and "Did the symptoms improve on absence from work?"

RESULTS

The response rate was 72%, 58% of the responders were women. 416 (70%) had work-related asthma. There were fewer smokers in the group with work-related asthma than among those without, atopy was equally prevalent. Occupational titles reflected the gender differences of the Norwegian labour force. Indoor climate at the workplace was stated as the most frequent provoking factor. The physicians suspected a relationship to work for about half of the 416, notification was only sent for 21% of the male and 10% of the female employees.

INTERPRETATION

The importance of occupational exposure seems to be underestimated, especially for women with asthma. Neither atopy nor smoking increased the risk for work-related symptoms. Indoors climate at the work place was most often given as the reason for work-related symptoms. A reduction of exposure led to a reduction of symptoms for most individuals.

Visuotopic mapping through a multichannel stimulating implant in primate V1

We report on our efforts to establish an animal model for the development and testing of a cortical visual prostheses. One-hundred-fifty-two electrodes were implanted in the primary visual cortex of a rhesus monkey. The electrodes were made from iridium with an activated iridium oxide film, which has a large charge capacity for a given surface area, and insulated with parylene-C. One-hundred-fourteen electrodes were functional after implantation. The activity of small (2-3) neuronal clusters was first recorded to map the visually responsive region corresponding to each electrode. The animal was then trained in a memory (delayed) saccade task, first with a visual target, then to a target defined by direct cortical stimulation with coordinates specified by the stimulating electrode's mapped receptive field. The SD of saccade endpoints was approximately 2.5 larger for electrically stimulated versus visual saccades; nevertheless, when trial-to-trial scatter was averaged out, the correlation between saccade end points and receptive field locations was highly significant and approached unity after several months of training. Five electrodes were left unused until the monkey was fully trained; when these were introduced, the receptive field-saccade correlations were high on the first day of use (R = 0.85, P = 0.03 for angle, R = 0.98, P < 0.001 for eccentricity), indicating that the monkey had not learned to perform the task empirically by memorizing reward zones. The results of this experiment suggest the potential for rigorous behavioral testing of cortical visual prostheses in the macaque.

Dimensions of sexuality in the perimenopausal transition: a model for practice

A biopsychosocial-cultural model of the sexuality of women during the perimenopausal transition includes dimensions related to physiology, psychosocial issues, and culture. It is an amalgam of biomedical and psychosocial models, yet has the added focus on culture. This holistic approach to sexual health is recommended by researchers and clinicians engaged in the study of midlife women. Clinicians can use this model to guide assessment and interventions, examining all of the dimensions of sexuality during the perimenopausal transition.

Symptom responses of midlife Filipina Americans

OBJECTIVE

The purpose of this study was to describe the perimenopausal symptom responses of Filipino American midlife women.

DESIGN

This cross-sectional, descriptive survey collected symptom response information on Filipino American midlife women aged 35 to 56 years (n = 165) who self-identified as Filipina American and were proficient in the English language. Women were recruited from community churches and social groups. A survey questionnaire comprised of health history questions and a symptom checklist with symptom response questions were completed by the participants.

RESULTS

The symptom responses of women were compared by age groups of 35 to 39 (n = 39), 40 to 44 (n = 40), 45 to 49 (n = 37), and 50 to 56 (n = 49) and by perimenopausal phases of premenopausal (n = 85), transitional (n = 33), and menopausal/postmenopausal (n = 47). Indications from chi 2 tests showed that women in the 35-to-39- and 50-to-56-year groups were more likely to take acetaminophen (Tylenol) or aspirin for symptoms, and women in the 45-to-49- and 50-to-56-year groups were more likely to be on hormone replacement therapy. Surprisingly, women in the 50-to-56-year group were less likely to use talking with friends as a symptom management strategy.

CONCLUSIONS

Nonpharmacologic symptom management strategies exceeded the use of medications (hormones, over-the-counter) by Filipina Americans. This may be a strong indicator of their positive attitude toward this phase in their life and sends a message to clinicians about the choices that these women make for symptom management. Culturally relevant care would include alternatives to hormone replacement therapy in education materials about the perimenopausal transition for midlife Filipinas.

Symptom experience of Filipino American midlife women

OBJECTIVE

The purpose of this study was to describe the perimenopausal symptom experience of Filipino American midlife women with particular emphasis upon estrogen-related menopause symptoms (day sweats, hot flashes, night sweats, and vaginal dryness).

DESIGN

A cross-sectional, descriptive survey was used to generate symptom experience data for 165 Filipina Americans between the ages of 35 and 56 who self-identified as Filipina American and were English-language proficient. The community-based sample completed questionnaires composed of sample characteristic questions and a 51-item menstrual symptom checklist with menopause-related symptoms embedded in it.

RESULTS

Sample characteristics and symptom experience were compared among age groups of 35 to 39 (n = 39), 40 to 44 (n = 40), 45 to 49 (n = 37), and 50 to 56 (n = 49) and by perimenopausal phase, defined as premenopausal (n = 85), transitional (n = 33), and menopausal/postmenopausal (n = 47). The most reported individual symptoms were "felt energetic" (86.1%) and "well-being" (83.6%). Estrogen-related menopause symptoms were reported as "vaginal dryness" (39.4%), "hot flashes" (37.6%), "day sweats" (27.9%), and "night sweats" (24.2%) by the total sample. Distress associated with estrogen-related menopause symptoms was reported by 17% (n = 28) of all women. Subjects' chi 2 tests indicated that 50-to-56-year-old women were more likely to report fatigue/sleep symptoms, physical symptoms, and estrogen-related menopause symptoms than all other age groups. When compared by perimenopausal phase, transitional women were more likely to report moderate or extreme severity for day sweats. Premenopausal women were more likely to report minimal or mild severity and women in the perimenopausal transition were more likely to report moderate or extreme severity on estrogen-related menopause symptoms.

CONCLUSIONS

Filipino American midlife women appear to consider the perimenopausal transition in a positive light and experience little distress associated with estrogen-related menopause symptoms experienced. Findings from this study suggest that Filipina Americans view perimenopausal symptoms as part of a normal life stage that does not warrant concern.

Gaining access to underresearched populations in women's health research

Culture is an important variable in women's health research, and sample selection must include plans to recruit participants who represent the overall cultural makeup of the population. However, gaining access to underresearched groups is a major challenge and requires specific planning. Salient access techniques utilized by epidemiological researchers include (a) obtaining the support and endorsement of community leaders, (b) advertising the research in community publications, and (c) utilizing age, gender, and culturally matched research assistants. Although these elements were included in the planning of a study of the perimenopausal transition of Filipino American midlife women, the more powerful attractors for this particular cultural group were their pride in participating in a study that was associated with a major university and their intense community service orientation. Since each cultural group has unique issues and concerns, researchers must familiarize themselves with the values of their target group and emphasize these in recruitment approaches.

The perimenopausal transition of Filipino American midlife women: biopsychosociocultural dimensions

OBJECTIVES

To describe the biologic, psychological, social, and cultural (biopsychosociocultural) dimensions of the perimenopausal transition of Filipino American midlife women.

METHODS

A community-based sample of 165 women (a) self-identified as Filipino American, (b) ages 35 to 56 years, and (c) English language proficient was recruited from churches and social groups.

RESULTS

Women in the study were born in the Philippines (93.3%), had lived in the United States an average of 18.4 +/- 8.7 years, were married or partnered (74.6%), had completed college (62.8%) or a graduate degree (15.9%), worked (full-time, 77.9%; part-time, 12.9%), had household incomes greater than $50,000 (>58%). Menopause ages were calculated from reports of last menstrual periods (natural, 48.9 +/- 4.9 years; surgical, 42.2 +/- 5.7 years). Neither the age at menarche nor the number of pregnancies and children born was significantly related to age at menopause. Calcium from food sources was generally low, and the Center for Epidemiological Studies Depression Scale (CES-D) revealed a 24.8% depression rate. The low prevalence of physical health problems confirms previous research that foreign-born individuals have better health than those born in the United States.

CONCLUSIONS

The profile of this understudied group identified calcium intake, osteoporosis morbidity, and prevalence of depression as key areas for future study.

Information sources, menopause beliefs, and health complaints of midlife Filipinas

Although the perimenopausal transition is a universal experience for women who live long enough, its cross-cultural variations have been explored only recently. In this study, we investigated some of the expectations and health beliefs of 165 midlife Filipina Americans using focus groups and a short-answer questionnaire. Participants reported on (a) how they learned about menopause, (b) who they talked to about menopause symptoms or issues, (c) how Filipino women and men feel about menopause, and (d) the most common health complaints of midlife Filipinas. Findings revealed that midlife Filipina Americans primarily obtain their information from and talk about menopause with female relatives and friends. They usually viewed menopause as a normal life phase, yet knew less about how Filipino men feel about menopause. Health complaints of midlife Filipinas were mainly estrogen-related menopause symptoms and negative affect symptoms.

One-step immunoaffinity purification of recombinant human retinoic acid receptor gamma

Retinoic acid receptors (RAR) are members of the steroid/thyroid hormone receptor superfamily and serve as ligand-activated transcription factors. In order to facilitate studies of receptor protein, we have generated a monoclonal antibody to the human RAR gamma, and have developed a procedure to purify the full-length receptor expressed in insect cells. The monoclonal antibody (A10) was developed using as antigen a carboxy-terminal fragment of the human RAR gamma expressed as a bacterial fusion protein. The A10 monoclonal antibody binds to both native and denatured forms of the human RAR gamma. This antibody was immobilized on a resin and used to purify full-length, baculovirus-expressed human RAR gamma to near homogeneity. The immunoaffinity-purified receptor is > 90-95% pure as revealed by silver-stained gels. The identity of the single protein band as RAR gamma was verified by immunoblotting using a polyclonal antibody to an epitope distinct from that recognized by the A10 antibody. The pure human RAR gamma is functional with respect to both ligand and DNA binding. Scatchard analysis of 3H-labeled all-trans retinoic acid binding to purified human RAR gamma revealed a single, high-affinity binding site with a Kd of approximately 2 nM. Binding of the pure RAR gamma to a DR5-type retinoic acid response element was also studied. Response element binding by RAR gamma required the presence of the retinoid X receptor, but did not require the presence of additional proteins. Human RAR gamma protein purified in this fashion will be useful in future structural and functional studies.

A study in normal human volunteers to compare the rate and extent of levothyroxine absorption from Synthroid and Levoxine

Numerous branded and generic formulations of levothyroxine (LT4) sodium tablets are currently available. Results from previous studies attempting to examine the comparative bioavailability of these formulations are difficult to interpret because of subject heterogeneity, single time-point blood sampling, varying degrees of hypothyroidism, and other factors. This study was devised to compare the rate and extent of absorption of LT4 from different LT4 sodium tablet formulations, in a simple model using a single-dose two-way single-blind, randomized cross-over design in 30 normal, healthy, nonpregnant, female subjects. This design controlled for many factors that limited previous LT4 bioavailability studies. Subjects were given a single 600 micrograms dose of LT4 as either Synthroid (Boots Pharmaceuticals, Inc., Lincolnshire, IL) tablets (formulation A) or Levoxine tablets (Daniels Pharmaceuticals, St. Petersburg, FL; formulation B). Measurements of baseline-corrected total T4 serum concentrations determined at multiple time points demonstrated statistically significant differences between the two formulations at the 1.00, 3.00, 5.00, and 18.00 hour sampling times. Statistically significant differences for area under the curve (AUC) (0 to 48 hours) (formulation A, 159.9 +/- 9.4 micrograms-hour/dL; formulation B, 193.4 +/- 10.1 micrograms-hour/dL) and maximum peak plasma concentration (Cmax) (formulation A, 5.91 +/- .34; formulation B, 7.12 +/- .32) also were demonstrated. Furthermore, the ratio of the baseline-corrected total T4 concentrations (B/A x 100) were 120.9% for AUC and 120.5% for Cmax. These data demonstrate that the administration of Synthroid and Levoxine result in a significantly different rate and extent of absorption of LT4, and therefore these two formulations cannot be considered bioequivalent.(ABSTRACT TRUNCATED AT 250 WORDS)

Na:K pump abundance and function in MDCK cells: effect of low ambient potassium

Side-specific expression and activity of Na:K pump was studied in Madin-Darby canine kidney (MDCK) cells, a tissue culture model of distal renal tubular epithelium, exposed to low ambient potassium. Confluent monolayers grown on teflon filters in dual chambers were treated with a low K+ medium from 45 min to 72 h. After both acute (45 min) and longer-term (24-72 h) exposure to low K+ (0.7 mM), cation cycling rate of existing pump units increased substantially, while there was no significant change in total cell Na-K-ATPase activity or in basolateral surface pump density. Although a small quantity of Na:K pumps (less than 10%) was consistently present apically, it also did not increase after exposure to low K+, or when the monolayers were provided K+ only from the apical side. In MDCK monolayers low K+ enhances the rate of K+ uptake by the existing pump units but does not increase the total number of pumps or their deployment on either cell surface.

Renal metabolism of atrial natriuretic peptide in the rat

The purpose of this study was to identify the nephron and cell sites involved in the renal metabolism of alpha-rat atrial natriuretic peptide (alpha-rANP) and to examine the degradation products of the peptide. In micro-dissected nephrons 125I-labeled ANP degradation rate was highest in proximal convoluted (PCT) and straight tubules and lowest in glomeruli and papillary collecting tubules, indicating that the sites of ANP degradation and of the receptors that mediate its biological activity in the nephron do not coincide. Among subcellular fractions of cortical homogenates, the luminal membranes were the most active in metabolizing ANP. In contrast, ANP degradation by isolated basolateral membranes was negligible, and the basolateral uptake route in intact tubules did not contribute significantly to its catabolism. Cortical homogenates, luminal membranes, and isolated PCT degraded ANP without evidence of saturation up to pharmacological concentrations (10(-6) M) of the peptide. A major intermediate metabolite was rapidly formed by luminal membranes and was identified with use of a sequence and compositional analysis. This metabolite had the same amino acid sequence as ANP with a cleavage at position Cys7-Phe8, and the disulfide bridge was preserved. These results demonstrate a rapid degradation of ANP by kidney tissue and suggest that the luminal membrane of the proximal tubule is a major nephron site of ANP catabolism.