Emergency department management of methamphetamine toxicity.

Management of patients who are acutely intoxicated with methamphetamine (a member of the substituted amphetamine class of drugs) can be resource-intensive for most emergency departments. Clinical presentations of the methamphetamine sympathomimetic toxidrome range from mild agitation to rhabdomyolysis, acute kidney injury, seizures, and intracranial hemorrhage. High-quality evidence on how to best manage these patients is lacking, and most research focuses on symptomatic interventions to control patients' agitation and hemodynamics. This review analyzes the best available evidence on the diagnosis and management of emergency department patients with substituted amphetamine toxicity and offers best-practice recommendations on treatment and disposition.

Sentinel Lymph Node Sampling in Robot-Assisted Staging of Endometrial Cancer.

OBJECTIVE: Sentinel lymph node (SLN) sampling in endometrial cancer staging has become an acceptable standard. Indocyanine green dye injected into the cervix and detected by near-infrared light is technically simple and sensitive. We aimed to evaluate SLN sampling in robot-assisted surgical staging of endometrial cancer at a university-affiliated teaching hospital. METHODS: A retrospective chart review, from January 2016 to December 2017, of patients who underwent robot-assisted surgical staging with cervical injection of indocyanine green dye detected by near-infrared light. The map rate, sensitivity, false negatives, and negative predictive value were calculated. RESULTS: A total of 105 charts were reviewed; 79 patients met inclusion criteria. The mean age was 65 (range 38-93) and the mean body mass index was 33.3 (range 16-49). Most patients (72.2%) had stage I disease and grade 1 or 2 histology (77.1%). Eight (10.1%) patients had lymph node metastasis. Seventy-two (91.1%) patients had positive mapping to at least 1 SLN. Sixty-two (78.5%) patients had bilateral mapping. Forty-four patients had concurrent pelvic ± para-aortic lymph node dissection and were included in the sensitivity analysis. Five of 44 cases had LN metastasis. The sensitivity was 80%, and the negative predictive value of SLN sampling was 97.5%. CONCLUSIONS: SLN mapping and sampling at a university-affiliated teaching hospital have comparable map rate, sensitivity, and negative predictive value as demonstrated in multiple trials. The technique has the potential to standardize endometrial cancer staging across different practice settings.

Challenges to Intraoperative Evaluation of Endometrial Cancer.

BACKGROUND AND OBJECTIVES: Intraoperative evaluation of the uterus has been reported to predict risk of lymph node spread in endometrial cancer. Four criteria have been prospectively validated by the Mayo Clinic; histopathology, grade, tumor size, and depth of myometrial invasion. The objective of this study is to assess the accuracy of intraoperative evaluation in a university-affiliated teaching setting. METHODS: This study was a retrospective chart review of 105 cases of endometrial cancer who underwent robotic-assisted staging from January 2016 through December 2017. RESULTS: Seventy-five cases were included. The mean age was 65 y and mean body mass index was 33 kg/m2. Fifty-eight patients (80.6%) had no change between intraoperative and postoperative grade. This yielded a 19.4% discordance rate with a significant disagreement (P = .003, Cohen's κ = 0.705). Fifty-eight patients (82.9%) had no change in depth of invasion. This yielded a 17.1% discordance rate with a significant disagreement (P = .0498, Cohen's kappa of 0.69 [95% confidence interval, 0.53-0.85]). Average tumor diameter was 3.4 cm. Seven patients (11.7%) were upsized from the low-risk (≤2 cm) to the high-risk category (>2 cm). This led to an 11.7% discordance rate, with a significant disagreement (P = .008, Cohen's kappa of 0.69 [95% confidence interval, 0.48-0.89]). In 15 of 75 cases (20%), intraoperative evaluation of the size of the tumor was not possible and deferred to the final pathology report. CONCLUSION: We conclude the Mayo Clinic Criteria cannot be universally adopted until all four criteria can be validated through a prospective study that includes institutions that have variable resources.

Handedness and the risk of glioma.

Gliomas are the most common type of malignant primary brain tumor and few risk factors have been linked to their development. Handedness has been associated with several pathologic neurological conditions such as schizophrenia, autism, and epilepsy, but few studies have evaluated a connection between handedness and risk of glioma. In this study, we examined the relationship between handedness and glioma risk in a large case-control study (1849 glioma cases and 1354 healthy controls) and a prospective cohort study (326,475 subjects with 375 incident gliomas). In the case-control study, we found a significant inverse association between left handedness and glioma risk, with left-handed persons exhibiting a 35% reduction in the risk of developing glioma [odds ratio (OR) = 0.65, 95% confidence interval (CI) 0.51-0.83] after adjustment for age, gender, race, education, and state of residence; similar inverse associations were observed for GBM (OR = 0.69, 95% CI 0.52-0.91), and non-GBM (OR = 0.59, 95% CI 0.42-0.82) subgroups. The association was consistent in both males and females, and across age strata, and was observed in both glioblastoma and in lower grade tumors. In the prospective cohort study, we found no association between handedness and glioma risk (hazards ratio = 0.92, 95% CI 0.67-1.28) adjusting for age, gender, and race. Further studies on this association may help to elucidate mechanisms of pathogenesis in glioma.

Stability of synthetic cathinones in oral fluid samples.

Synthetic cathinones are new stimulant drugs derived from cathinone that have been sold as "legal highs" worldwide. These compounds can elicit powerful effects such as delusions, hallucinations as well as other potentially dangerous behavior. New analogs with varying effects and potencies are constantly introduced in the market to evade legislation, and they are not detected by routine screening and confirmation methods. Oral fluid is an alternative matrix of increasing interest in forensic toxicology. Its collection is non-invasive and easily supervised, and positive drug findings typically reflect recent drug exposure. The focus of this research was to develop a method for the determination of 10 synthetic cathinones (cathinone, methcathinone, buphedrone, mephedrone, 4-methylethcathinone, 3,4-methylenedioxypyrovalerone (MDPV), methylone, naphyrone, alpha-pyrrolidinovalerophenone (PVP) and N-ethylcathinone) in preserved oral fluid (Quantisal™), as well as evaluate their stability in preserved (Quantisal and Oral-Eze™) and neat oral fluid samples stored under different conditions, using ultrahigh-performance liquid chromatography-tandem mass spectrometry (UHPLC-MSMS). Four-hundred microliters oral fluid-Quantisal buffer mixture (100µL oral fluid and 300µL buffer) were subjected to cation exchange solid phase extraction. The chromatographic reverse-phase separation was achieved with a gradient mobile phase of 0.1% formic acid in water and in acetonitrile in 5min. We used a Shimadzu triple quadrupole mass spectrometer in multiple reaction monitoring (MRM) mode. The assay was linear from 1 to 250ng/mL, with the limits of detection of 0.75-1ng/mL. Imprecision (n=15) was <20.7% and accuracy (n=15) was 84-115.3%. Extraction efficiency was 87.2-116.8% (n=6), process efficiency was 30.9-103.7% (n=6), and matrix effect was -65.1 to -6.2% (CV 2.5-15.1%, n=6). The stability was performed for neat oral fluid, oral fluid in Quantisal buffer, and oral fluid in Oral-Eze buffer samples stored up to one month at room temperature, 4°C and -20°C, and after 3 freeze-thaw cycles. Losses up to -71.2 to -100% were observed in neat and preserved samples stored at room temperature up to one month. At 4°C, losses up to -88.2% occurred in neat OF and Oral-Eze samples, while Quantisal samples showed losses up to -34%. All types samples were stable if stored at -20°C and after 3 freeze-thaw cycles.