Presence of kratom in opioid overdose deaths: findings from coroner postmortem toxicological report

Background

Kratom (Mitragyna speciosa) use in the United States is becoming increasingly popular and its legal status varies widely from state to state. Multiple reports of adverse events associated with kratom use have ranged from liver injury, seizures, psychiatric disturbance, and rarely death.

Methods

This study investigated coroner autopsy reports from Kern County in California for the year 2020 which included qualitative data on substances from blood toxicological reports. Of the 214 opioid-associated accidental overdoses reported, 4 subjects (1.9%) had mitragynine (kratom) exposure on the autopsy report and were included in the study. We reported available demographic information and comorbid substance findings from the associated autopsy reports.

Results

All 4 individuals with mitragynine (kratom) toxicology had accidental opioid overdose deaths noted in autopsy reports. Each subject also had toxicology positive for at least one other substance. Fentanyl was found in 3 (75%) of the cases and suspected to be the primary contributor to opioid-related deaths in those cases. However, one fatality was without fentanyl, but instead had tested positive for benzodiazepines, cannabis, and other psychiatric medications.

Discussion

The findings of this brief report provide insight into the role that mitragynine (kratom) may have in modulating risk of opioid-related deaths. The combined use of kratom with opioids such as fentanyl appears most likely to increase the risk of a fatal overdose, but it may also occur with other medications such as benzodiazepines and psychiatric medications. It is a serious concern that in the midst of the opioid overdose epidemic there is a growing presence of kratom use in the U.S. population with a largely unregulated status.

Suspected Aripiprazole-induced neutropenia in a geriatric patient: a case report

Background

Aripiprazole, a third-generation antipsychotic medication, has been used to treat a range of psychiatric disorders. According to the U.S. Food and Drug Administration’s prescribing information, the most common adverse reactions in adult patients in clinical trials (≥10%) were nausea, vomiting, constipation, headache, dizziness, akathisia, anxiety, and insomnia. While hematological adverse effects may occur with aripiprazole, there is very limited information in the published literature on such adverse outcomes.

Case presentation

A 68-year-old Caucasian male with treatment resistant depression was hospitalized for suicidal ideation. The patient developed neutropenia after aripiprazole was introduced as an augmentation agent. The neutropenia was reversible with discontinuation of the medication.

Conclusions

To our knowledge, we describe the first case report of suspected neutropenia-induced by aripiprazole use in a geriatric patient. While hematological adverse reactions are rare, we recommend adding CBC to the standard adverse systemic reaction monitoring of antipsychotic medications, particularly among the elderly.

Living near a freeway is associated with lower bone mineral density among Mexican Americans

We hypothesized that chronic exposures to traffic combustion products may lower bone mineral density (BMD). We found that proximity to freeways was associated with reduced BMD. Our findings suggest that traffic-related pollution may contribute to the occurrence of osteopenia and osteoporosis.

INTRODUCTION

Adults residing in rural areas have been linked with higher BMD. We aimed to determine if this difference is due in part to air pollution by examining the relationships between traffic metrics and ambient air pollution with total body and pelvic BMD.

METHODS

Mexican American adults (n = 1,175; mean 34 years; 72 % female) who had participated in the BetaGene study of air pollution, obesity, and insulin resistance were included in this analysis. Total body and pelvic BMD were estimated using dual-energy X-ray absorptiometry. Traffic and ambient air pollutant exposures were estimated at residences using location and ambient monitoring data. Variance component models were used to analyze the associations between residential distance to the nearest freeway and ambient air pollutants with BMD.

RESULTS

Residential proximity to a freeway was associated with lower total body BMD (p-trend = 0.01) and pelvic BMD (p-trend = 0.03) after adjustment for age, sex, weight, and height. The adjusted mean total body and pelvic BMD in participants living within 500 m of a freeway were 0.02 and 0.03 g/cm(2) lower than participants living greater than 1,500 m from a freeway. These associations did not differ significantly by age, sex, or obesity status. Results were similar after further adjustment for body fat and weekly physical activity minutes. Ambient air pollutants (NO2, O3, and PM2.5) were not significantly associated with BMD.

CONCLUSIONS

Traffic-related exposures in overweight and obese Mexican Americans may adversely affect BMD. Our findings indicate that long-term exposures to traffic may contribute to the occurrence of osteoporosis and its consequences.

A novel low-power-implantable epileptic seizure-onset detector

A novel implantable low-power integrated circuit is proposed for real-time epileptic seizure detection. The presented chip is part of an epilepsy prosthesis device that triggers focal treatment to disrupt seizure progression. The proposed chip integrates a front-end preamplifier, voltage-level detectors, digital demodulators, and a high-frequency detector. The preamplifier uses a new chopper stabilizer topology that reduces instrumentation low-frequency and ripple noises by modulating the signal in the analog domain and demodulating it in the digital domain. Moreover, each voltage-level detector consists of an ultra-low-power comparator with an adjustable threshold voltage. The digitally integrated high-frequency detector is tunable to recognize the high-frequency activities for the unique detection of seizure patterns specific to each patient. The digitally controlled circuits perform accurate seizure detection. A mathematical model of the proposed seizure detection algorithm was validated in Matlab and circuits were implemented in a 2 mm(2) chip using the CMOS 0.18- μm process. The proposed detector was tested by using intracerebral electroencephalography (icEEG) recordings from seven patients with drug-resistant epilepsy. The seizure signals were assessed by the proposed detector and the average seizure detection delay was 13.5 s, well before the onset of clinical manifestations. The measured total power consumption of the detector is 51 μW.

Genetic variations in nitric oxide synthase and arginase influence exhaled nitric oxide levels in children

BACKGROUND

Exhaled nitric oxide (FeNO) is a biomarker of airway inflammation. In the nitric oxide (NO) synthesis pathway, nitric oxide synthases (encoded by NOS1, NOS2A, and NOS3) and arginases (encoded by ARG1 and ARG2) compete for L-arginine. Although FeNO levels are higher in children with asthma/allergy, influence of these conditions on the relationships between variations in these genes and FeNO remains unknown. The aims of the study were to evaluate the role of genetic variations in nitric oxide synthases and arginases on FeNO in children and to assess the influence of asthma and respiratory allergy on these genetic associations.

METHODS

Among children (6-11 years) who participated in the southern California Children's Health Study, variations in these five genetic loci were characterized by tagSNPs. FeNO was measured in two consecutive years (N = 2298 and 2515 in Years 1 and 2, respectively). Repeated measures analysis of variance was used to evaluate the associations between these genetic variants and FeNO.

RESULTS

Sequence variations in the NOS2A and ARG2 loci were globally associated with FeNO (P = 0.0002 and 0.01, respectively). The ARG2 association was tagged by intronic variant rs3742879 with stronger association with FeNO in asthmatic children (P-interaction = 0.01). The association of a NOS2A promoter haplotype with FeNO varied significantly by rs3742879 genotypes and by asthma.

CONCLUSION

Variants in the NO synthesis pathway genes jointly contribute to differences in FeNO concentrations. Some of these genetic influences were stronger in children with asthma. Further studies are required to confirm our findings.

The effect of ambient air pollution on exhaled nitric oxide in the Children's Health Study

We assessed the effect of daily variations in ambient air pollutants on exhaled nitric oxide fraction (F(eNO)) using data from a cohort of school children with large differences in air pollutant exposures from the Children's Health Study. Based on a cohort of 2,240 school children from 13 Southern Californian communities, cumulative lagged average regression models were fitted to determine the association between F(eNO) and ambient air pollution levels from central site monitors with lags of up to 30 days prior to F(eNO) testing. Daily 24-h cumulative lagged averages of particles with a 50% cut-off aerodynamic diameter of 2.5 µm (PM₂.₅; over 1-8 days) and particles with a 50% cut-off aerodynamic diameter of 10 µm (PM₁₀; over 1-7 days), as well as 10:00-18:00 h cumulative lagged average of O₃ (over 1-23 days) were significantly associated with 17.42% (p<0.01), 9.25% (p<0.05) and 14.25% (p<0.01) higher F(eNO) levels over the interquartile range of 7.5 μg·m⁻³, 12.97 μg·m⁻³ and 15.42 ppb, respectively. The effects of PM₂.₅, PM₁₀ and O₃ were higher in the warm season. The particulate matter effects were robust to adjustments for effects of O₃ and temperature and did not vary by asthma or allergy status. In summary, short-term increases in PM₂.₅, PM₁₀ and O₃ were associated with airway inflammation independent of asthma and allergy status, with PM₁₀ effects significantly higher in the warm season.

Exhaled nitric oxide, susceptibility and new-onset asthma in the Children's Health Study

A substantial body of evidence suggests an aetiological role of inflammation, and oxidative and nitrosative stress in asthma pathogenesis. Exhaled nitric oxide fraction (F(eNO)) may provide a noninvasive marker of oxidative and nitrosative stress, and aspects of airway inflammation. We examined whether children with elevated F(eNO) are at increased risk for new-onset asthma. We prospectively followed 2,206 asthma-free children (age 7-10 yrs) who participated in the Children's Health Study. We measured F(eNO) and followed these children for 3 yrs to ascertain incident asthma cases. Cox proportional hazard models were fitted to examine the association between F(eNO) and new-onset asthma. We found that F(eNO) was associated with increased risk of new-onset asthma. Children in the highest F(eNO) quartile had more than a two-fold increased risk of new-onset asthma compared to those with the lowest quartile (hazard ratio 2.1, 95% CI 1.3-3.5). This effect did not vary with the child's history of respiratory allergic symptoms. However, the effect of elevated F(eNO) on new-onset asthma was most apparent among those without a parental history of asthma. Our results indicate that children with elevated F(eNO) are at increased risk for new-onset asthma, especially if they have no parental history of asthma.