Opioid Toxidrome Following Grapefruit Juice Consumption in the Setting of Methadone Maintenance.

BACKGROUND: Methadone is a synthetic mu-opioid receptor agonist used in the treatment of chronic pain and opioid dependence. Methadone is metabolized by several cytochrome P450 isoenzymes; primarily CYP3A4, CYP2B6, and CYP2D6 before renal and fecal elimination. Exposure to substances like grapefruit juice, that inhibit these isoenzymes may result in increased blood levels of methadone, and thus may manifest clinically as unexpected opioid toxicity. CASE: A 51-year-old male was found unresponsive. He was hypoxic and bradypneic with pinpoint pupils. Multiple boluses followed by infusion of naloxone were required before improvement of respiratory status. Upon awakening, the patient reported participating in an opioid treatment program where he is administered 90 mg of oral methadone daily and denied any other substance use. On further questioning, he admitted to drinking grapefruit juice (estimated to be approximately 500 mL/day) every day for 3 consecutive days before presentation. The patient was discharged home after being counseled to stop drinking grapefruit juice. DISCUSSION: Grapefruit juice is known to be an inhibitor of the CYP3A4 isoenzyme. Various studies demonstrate that through CYP3A4 inhibition, grapefruit juice increases serum levels of opioids, such as methadone, though no clinically significant effects have been reported. CONCLUSIONS: Grapefruit juice inhibits the metabolism of methadone, raising its serum levels. To our knowledge, this is the first reported case in which the interaction between grapefruit juice and methadone was significant enough to cause an opioid toxidrome. It is, therefore, recommended that opioid treatment programs (OTPs) advise patients about this interaction before administering methadone.

Pulmonary Function Testing in Dentists Versus Controls: A Pilot Study Exploring the Potential Respiratory-Related Occupational Hazards of Dentistry.

OBJECTIVE: Minimal research exists evaluating respiratory-related occupational hazards associated with dentistry in the United States. The purpose of this study was to evaluate the pulmonary function of dentists as compared with controls. METHODS: This is a case-control study evaluating pulmonary function in dentists versus controls. Outcomes included measurements of percent predicted FEV1 (FEV1%), percent of predicted FVC (FVC%), and forced expiratory volume in one second (FEV1)/forced vital capacity (FVC). RESULTS: Our findings indicate that dentists had a statistically significant lower percent predicted FEV1% (P < 0.05) and FVC% (P < 0.05) compared with controls. The prevalence of abnormal FVC% and FEV1% was greater among dentists, but only the increase in abnormal FEV1% approached significance. CONCLUSIONS: Dentists had lower percent predicted values for FVC% and FEV1% versus controls. More research is required to further investigate the association between the dental profession and pulmonary function in dentists.

Hemolytic Crisis following Naphthalene Mothball Ingestion in a 21-Month-Old Patient with Glucose-6-Phosphate Dehydrogenase (G6PD) Deficiency.

INTRODUCTION: Naphthalene is an aromatic hydrocarbon that may be found in mothballs and deodorizers. Exposure can occur by ingestion or dermal absorption. We present a case of acute hemolysis requiring blood transfusion in a 21-month-old male with a history of glucose-6-phosphate dehydrogenase (G6PD) deficiency after ingestion of a naphthalene-containing mothball. CASE PRESENTATION: A 21-month-old male with G6PD deficiency presented to the emergency department three hours following an exploratory ingestion of a naphthalene-containing mothball. On arrival, the patient was tachycardic with normal blood pressure, temperature, respiratory rate, and oxygen saturation. Initial laboratory studies showed significant anemia with elevated reticulocyte count, blood urea nitrogen, total bilirubin, and lactate dehydrogenase. Haptoglobin level was low, and the methemoglobin level was unremarkable. The patient was admitted to the pediatric intensive care unit and underwent blood transfusion. DISCUSSION: This case serves as a reminder that mothballs, a ubiquitous household item, can be hazardous when accessible to vulnerable children. Care should be taken to secure these products and prevent ingestion.

Gadolinium Aspiration Following Inadvertent Endotracheal Tube Cuff Injection in a Pediatric Patient.

INTRODUCTION: Gadolinium-based contrast agents (GBCA) are frequently used for MRI contrast studies. We report a case of pulmonary aspiration secondary to inadvertent GBCA injection. CASE REPORT: A 12-year-old female with a past medical history significant for mitochondrial disorder, bronchial asthma, autism, recurrent urinary tract infection, epilepsy, developmental delay, dysautonomia, and thrombocytopenia was scheduled for a contrast-enhanced MRI study using gadoterate meglumine for urinary incontinence. The patient was sedated and intubated in preparation for the study, during which 10 mL of gadoterate meglumine was inadvertently injected into the endotracheal tube cuff pilot line instead of intravenously. The patient remained intubated and was admitted to the intensive care unit with continuous monitoring for signs of pulmonary injury or gadolinium toxicity. She was successfully extubated approximately 24 hours later without complication. DISCUSSION: A variety of adverse effects attributable to parenteral GBCA exposure have been reported ranging from mild irritation to life-threatening anaphylaxis. Gadolinium deposition and storage have been implicated in a number of those adverse effects and multiple treatments modalities have been suggested, but no scientifically guided management exists. CONCLUSION: This case of pulmonary aspiration secondary to inadvertent GBCA injection in a pediatric patient demonstrated no acute  side effects or complications within the first 24 hours. With the wide range of adverse effects attributed to gadolinium use in the medical literature, it is difficult to predict potential future adverse effects.

Urine uranium concentrations and renal function in residents of the United States--2001 to 2010.

CONTEXT: Animal model studies have demonstrated that subchronic oral uranium exposure is associated with renal dysfunction. Little is known about the effects of environmental exposure to uranium in humans. OBJECTIVE: To determine whether environmental exposure to uranium is associated with alterations in renal function among residents of the United States. METHODS: We analyzed data from the National Health and Nutrition Examination Survey (NHANES) 2001-2010. Inclusion criteria included the measurement of urine uranium concentration, serum creatinine (sCr), and urine albumin-creatinine ratio. Exclusion criteria included a reported history of diabetes mellitus. Urine uranium concentrations were normalized to urinary creatinine. Respondents with and without detectable urine uranium concentrations were compared using Welch's t-test for urine albumin-creatinine ratio and sCr and using Fisher's exact test for a reported history of renal disease. Regression analysis was performed to assess for an association between urine uranium concentration and urine albumin-creatinine ratio, sCr, or a reported history of renal disease. RESULTS: Uranium was detectable in the urine of 74.1% (n = 9025) of respondents. Urine albumin-creatinine ratio was significantly greater in respondents with detectable urine uranium concentrations (mean 4.84 ± 45.8 mg/g) compared to respondents without detectable urine uranium concentrations (mean 0.77 ± 3.7 mg/g) (p < 0.001). There was no significant difference between the groups with respect to sCr or a reported history of renal disease. Regression analysis did not show a statistically significant association between urine uranium concentration and urine albumin-creatinine ratio (p = 0.45), sCr (p = 0.71), or a reported history of renal disease (p = 0.05). CONCLUSIONS: In this study, a high proportion of the U.S. population had exposure to uranium. We demonstrated an association between detectable urine uranium concentrations and microalbuminuria in residents of the United States but no association with clinical renal disease.

Change in perceived risk associated with marijuana use in the United States from 2002 to 2012.

CONTEXT: The role of a dynamic legal, medical, and social setting in affecting the perceived risk associated with smoking marijuana has not been well studied. We sought to determine whether there has been a change in the perceived risk associated with marijuana use over time. METHODS: A cross-sectional study was conducted using the 2002-2012 National Survey on Drug Use and Health. Respondents were asked to classify the risk of smoking marijuana. Regression analysis and the Mann-Whitney U test were used to analyze the data. RESULTS: A total of 614579 respondents were identified. Between 2002 and 2012, the percent of respondents who characterized regular marijuana use as being associated with "great risk" decreased from 51.3% to 40.3%, while the percent of respondents who characterized it as being associated with "no risk" increased from 5.7% to 11.7%. The percent of respondents who characterized occasional use as "great risk" decreased from 38.2% to 30.7%, while the percent of respondents who characterized it as "no risk" increased from 10% to 16.3%. There was a significant negative temporal trend in the perceived risk for both occasional and regular use of marijuana from 2002 to 2012 after controlling for age and gender (p < 0.001 for both). Increasing age was significantly associated with increased perceived risk for both occasional and regular marijuana use (p < 0.001). Males have a significantly lower perceived risk for regular marijuana use as compared with females (p < 0.001). Individuals who used marijuana during the preceding month reported a lower risk perception in both regular and occasional use. CONCLUSION: Between 2002 and 2012, there was a significant decrease in the perceived risk associated with occasional and regular marijuana use. Younger age, male gender, and past month use were also associated with decreased perceived risk.

Effect of single-dose Ginkgo biloba and Panax ginseng on driving performance.

CONTEXT: Panax ginseng and Gingko biloba are commonly used herbal supplements in the United States that have been reported to increase alertness and cognitive function. OBJECTIVE: The objective of this study was to investigate the effects of these specific herbals on driving performance. MATERIALS AND METHODS: 30 volunteers were tested using the STISIM3® Driving Simulator (Systems Technology Inc., Hawthorne, CA, USA) in this double-blind, placebo-controlled study. The subjects were randomized into 3 groups of 10 subjects per group. After 10-min of simulated driving, subjects received either ginseng (1200 mg), Gingko (240 mg), or placebo administered orally. The test herbals and placebo were randomized and administered by a research assistant outside of the study to maintain blinding. One hour following administration of the herbals or placebo, the subjects completed an additional 10-min of simulated driving. Standard driving parameters were studied including reaction time, standard deviation of lateral positioning, and divided attention. Data collected for the divided attention parameter included time to response and number of correct responses. The data was analyzed with repeated-measures analysis of variance (ANOVA) and Kruskal-Wallis test using SPSS 22 (IBM, Armonk, NY, USA). RESULTS: There was no difference in reaction time or standard deviation of lateral positioning for both the ginseng and Ginkgo arms. For the divided attention parameter, the response time in the Ginkgo arm decreased from 2.9 to 2.5 s. The ginseng arm also decreased from 3.2 to 2.4 s. None of these values were statistically significant when between group differences were analyzed. DISCUSSION AND CONCLUSION: The data suggests there was no statistically significant difference between ginseng, Ginkgo or placebo on driving performance. We postulate this is due to the relatively small numbers in our study. Further study with a larger sample size may be needed in order to elucidate more fully the effects of Ginkgo and ginseng on driving ability.

K2--not the spice of life; synthetic cannabinoids and ST elevation myocardial infarction: a case report.

INTRODUCTION: The adverse effects of synthetic cannabinoids are not well-described nor have they been thoroughly studied. CASE REPORT: A 16-year-old male with a past medical history of asthma and attention deficit hyperactivity disorder (ADHD) presented to the emergency department (ED) complaining of 24 h of substernal pressure associated with dyspnea, nausea, and vomiting. He reported smoking tobacco cigarettes daily and occasional marijuana use but denied recent use of marijuana. The initial electrocardiogram (EKG) revealed ST-segment elevations in leads II, III, AVF, and V4-V6. The initial troponin level was reported as 1.47 ng/mL, and the initial creatine kinase MB (CKMB) level was 17.5 ng/mL. The patient admitted to smoking "K2" 60-90 min prior to the onset of symptoms. The patient manifested persistent ST elevations with a peak troponin of 8.29 ng/mL. The urine drug immunoassay was positive for benzodiazepines and opiates. Cardiac catheterization revealed normal coronary arteries, no wall motion abnormalities, and normal systolic function. DISCUSSION: Synthetic cannabinoids may have significant potential adverse effects. Chest pain due to myocardial ischemia is rare in adolescents. When evaluating patients with chest pain, it is important to elicit a detailed drug history, specifically inquiring about synthetic cannabinoid use. Urine drug immunoassays may be unreliable and in this case did not detect synthetic cannabinoids.