Severe toxicity following synthetic cannabinoid ingestion.

OBJECTIVE: To report a case of seizures and supraventricular tachycardia (SVT) following confirmed synthetic cannabinoid ingestion. BACKGROUND: Despite widespread use of legal synthetic cannabinoids, reports of serious toxicity following confirmed use of synthetic cannabinoids are rare. We report severe toxicity including seizures following intentional ingestion of the synthetic cannabinoid JWH-018 and detail confirmation by laboratory analysis. CASE REPORT: A healthy 48 year old man had a generalized seizure within thirty minutes of ingesting an ethanol mixture containing a white powder he purchased from the Internet in an attempt to get high. Seizures recurred and abated with lorazepam. Initial vital signs were: pulse, 106/min; BP, 140/88 mmHg; respirations, 22/min; temperature, 37.7 °C. A noncontrast computed tomography of the brain and EEG were negative, and serum chemistry values were normal. The blood ethanol concentration was 3.8 mg/dL and the CPK 2,649 U/L. Urine drug screening by EMIT was negative for common drugs of abuse, including tetrahydrocannabinol. On hospital day 1, he developed medically refractory SVT. The patient had no further complications and was discharged in his normal state of health 10 days after admission. The original powder was confirmed by gas chromatography mass spectrometry to be JWH-018, and a primary JWH-018 metabolite was detected in the patient's urine (200 nM) using liquid chromatography tandem mass spectrometry. DISCUSSION: Synthetic cannabinoids are legal in many parts of the world and easily obtained over the Internet. Data on human toxicity are limited and real-time confirmatory testing is unavailable to clinicians. The potential for toxicity exists for users mistakenly associating the dose and side effect profiles of synthetic cannabinoids to those of marijuana. CONCLUSION: Ingestion of JWH-018 can produce seizures and tachyarrhythmias. Clinicians, lawmakers, and the general public need to be aware of the potential for toxicity associated with synthetic cannabinoid use.

Assessment of failed arthroscopic anterior labral repairs. Findings at open surgery.

To assess capsulolabral lesions present in patients after unsuccessful arthroscopic procedures, we reviewed the records of 20 patients who had undergone open shoulder procedures after unsuccessful arthroscopic Bankart procedures for chronic shoulder instability. The Bankart lesion had initially been repaired arthroscopically by transglenoid sutures (N = 10), bioabsorbable tacks (N = 7), suture anchors (N = 2), or arthroscopic screws (N = 1). Five of the 20 patients (25%) had reinjuries to the shoulder after the arthroscopic procedure. The average time from the arthroscopic to the open procedure was 17.9 months. Overall, 12 of the 20 patients (60%) had healed Bankart lesions at the time of open surgery. Eight of the 20 patients (40%) were found to have persistent Bankart lesions, and 15 of the 20 patients (75%) were found to have redundant anterior capsules. The presence of a persistent Bankart lesion significantly correlated with postarthroscopic dislocation, and the presence of capsular laxity significantly correlated with postarthroscopic subluxation. We concluded that capsular laxity is difficult to quantify arthroscopically and is present in a significant percentage of patients with chronic traumatic shoulder instability. Failure to successfully treat either the Bankart lesion or capsular laxity at the time of an arthroscopic Bankart procedure may lead to postoperative instability.

Outcomes of the Chrisman-Snook and modified-Broström procedures for chronic lateral ankle instability. A prospective, randomized comparison.

We prospectively and randomly compared the outcomes of the Chrisman-Snook and modified-Broström procedures for chronic lateral ankle instability in 40 patients. Both operations provided good or excellent stability in more than 80% of the patients. However, the modified-Broström procedure resulted in higher Sefton scores than the Chrisman-Snook procedure. In addition, a statistically significant greater proportion of complications occurred in patients treated with the Chrisman-Snook procedure.

Arthroscopic anterior labral reconstruction using a transglenoid suture technique. Results in active-duty military patients.

We report the clinical outcome of arthroscopic labral reconstruction using a transglenoid suture technique in a young, active-duty military population. Forty-eight patients (49 shoulders) with varying degrees of glenohumeral instability underwent arthroscopic labral reconstruction using a transglenoid suture technique. All patients had traumatic injuries to their shoulders and all patients had magnetic resonance imaging scans demonstrating anterior labral tears. Postoperatively, the patients' shoulders were immobilized for up to 6 weeks. At a mean followup of 30 months (range, 12 to 49), 17 of the 41 patients (41%) with preoperative dislocation or subluxation had recurrent instability. Nine of these patients subsequently underwent open reconstruction procedures for recurrent instability. On the basis of the Rowe rating system, 53% had excellent or good results and 47% had fair or poor results. The overall perioperative complication rate was 14%. Suprascapular nerve palsy occurred in three cases (6%). Using the Fisher exact test, we determined that immobilization for 6 weeks postoperatively correlated with a lower recurrence rate in the patients with a history of glenohumeral dislocation (P = 0.007). The results of arthroscopic labral reconstruction using transglenoid sutures in the military patient are inferior to the reported 3% to 5% recurrence rate with open Bankart procedures, and the transglenoid pin technique jeopardizes the suprascapular nerve.

Lateral traction during shoulder arthroscopy: its effect on tissue perfusion measured by pulse oximetry.

We studied the effect of three methods of shoulder traction during arthroscopy on arterial oxygen saturation measured by a pulse oximeter applied to the fingertip of the arm in traction. Simple longitudinal traction ablated the oxygen saturation in only 1 of 30 patients. Adding vertical traction perpendicular to the arm ablated the oxygen saturation in 25 of 30 patients when a 2-inch wide sling was used and in 7 of 30 patients when a 4-inch sling was used. In this series, the pulse oximeter did not demonstrate gradual gradations in arterial oxygen saturation loss. Rather, the pulse oximeter provided an all-or-none warning signal for tissue hypoxia.

Hill-Sachs lesion: comparison of detection with MR imaging, radiography, and arthroscopy.

Magnetic resonance (MR) imaging has proved to be a valuable method for documenting Hill-Sachs lesions. The authors retrospectively analyzed the diagnostic interpretations at plain film radiography, arthroscopy, and MR imaging in 76 patients. The analysis revealed that neither radiography nor arthroscopy displayed the lesion with sufficient accuracy to represent a true standard of reference for the evaluation of MR imaging in the diagnosis of the Hill-Sachs lesion. The data from the diagnostic interpretations were analyzed in three ways, each of which revealed that findings at MR imaging were more helpful than findings at radiography and/or arthroscopy in the diagnosis of the Hill-Sachs lesion. When the agreement of findings in two or three methods was used to assign a final diagnosis, MR imaging resulted in sensitivity of 97%, specificity of 91%, and accuracy of 94% in the detection of Hill-Sachs lesions.

Tears of the glenoid labrum: MR imaging of 88 arthroscopically confirmed cases.

Two hundred eighty-one patients underwent magnetic resonance (MR) imaging of the shoulder over a 2-year period. Eighty-eight patients underwent arthroscopic surgery, and their surgical results were correlated with the findings at MR imaging. MR imaging enabled accurate prediction of anterior labral tears, with a sensitivity of 95%, a specificity of 86%, and an accuracy of 92%. MR imaging was less effective in the prediction of tears of the superior labrum, with a sensitivity of 75%, a specificity of 99%, and an accuracy of 95%. These two categories accounted for the majority of the surgically correctable disease. MR imaging was found to be unreliable in the prediction of posterior (sensitivity, 7.7%) or inferior (sensitivity, 40%) labral tears, isolated cases of which occurred in only two (2%) of those undergoing surgery. MR imaging proved to be a highly accurate, noninvasive technique for the clinical evaluation of shoulder instability.

Four cases of injury involving soda vending machines.

Injuries resulting from rocking soda vending machines are severe and potentially fatal. Four cases of significant trauma stemming from soda vending machine accidents are reported: One patient died, one is disabled, and two healed uneventfully. As a result, we recommend securing heavy soda vending machines to prevent further injuries. To our knowledge, this is the first report on a mechanism of injury resulting from soda machines.